Failure to Prevent Resident-to-Resident Physical Abuse in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy and provide an environment free from abuse, resulting in one resident physically assaulting his roommate. Resident 1 (R1), an older adult with diagnoses including encounter for palliative care, cognitive communication deficit, anxiety disorder, and depression, was being assisted to bed by a CNA (V20) at approximately 10:00 PM. During this process, R1 requested two pillowcases. V20 left the room briefly to obtain the pillowcases, leaving R1 and his roommate, Resident 2 (R2), alone in the room. While R2 was asleep in bed, R1 fell from his wheelchair to the floor, crawled over to R2’s bed, and began hitting R2’s legs with his fists multiple times. R2, an older adult with a BIMS score of 15/15 and medical diagnoses including fractures of the first lumbar vertebra, right clavicle, and left humerus, reported that he felt a little pain and was more afraid than anything during the incident. When V20 re-entered the room, she heard R2 cry out and observed R1 on R2’s side of the room, holding on to R2. V20 immediately separated the two residents and notified the floor nurse (V22). The facility’s final investigation notes corroborated that V20 had stepped away briefly to obtain pillowcases at R1’s request and, upon returning, heard R2 say that R1 was grabbing him. This sequence of events demonstrates that the facility did not ensure an environment free from abuse as required by its Abuse and Neglect Policy, which states that professional care and services must be provided in an environment free from any type of abuse.
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