F0600

G

Resident-to-Resident Physical Abuse Resulting in Traumatic Injuries and Death

Dublin, Ohio Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse by a roommate, resulting in actual physical harm. One resident (Resident #51), who had Parkinson’s disease, dementia with severe cognitive impairment, psychotic and mood disturbances, anxiety disorder, repeated falls, and major depressive disorder, shared a room with another resident (Resident #21) who had bipolar disorder, schizophrenia, hearing loss, dementia, psychotic and mood disturbances, and anxiety disorder, but was assessed as cognitively intact. Resident #51 used a walker and wheelchair and required setup assistance for some mobility tasks but was otherwise independent with certain bed mobility. The facility’s abuse policy defined abuse as the willful infliction of injury or intimidation with resulting physical harm, including resident-to-resident altercations.

On the evening of the incident, staff heard Resident #51 yelling and a loud noise from the room shared by Residents #51 and #21. When staff entered, they found Resident #51 lying on the floor, with his head and torso outside the room and his legs inside, and Resident #21 standing over him, yelling profanities and making threatening statements such as, “touch me again and next time you won’t be able to stand back up,” and “I promise next time, you won’t get up.” Resident #51 appeared fearful and confused. A full body assessment revealed a raised, reddened area with a small amount of bleeding on the back of his head and a laceration on his right arm. The incident itself was unwitnessed by staff, but Resident #21 admitted to staff, the DON, and the Administrator that he had smacked or pushed Resident #51, causing him to fall, reportedly because he believed Resident #51 had urinated on the toilet seat.

Resident #51 was sent to the hospital for evaluation following the incident. Hospital records documented that a CT scan of the head showed a small interhemispheric falx subdural hematoma, and imaging also revealed an acute traumatic fracture through bridging anterior osteophyte at C5–C6 extending through the body of C6, as well as an acute traumatic C6 vertebral body fracture. The hospital discharge diagnoses included cardiorespiratory arrest, acute hypoxic respiratory failure, suspected aspiration with significant oropharyngeal secretions, oropharyngeal dysphagia, advanced dementia, acute traumatic fall, acute traumatic C5–C6 osteophyte fracture, and acute traumatic C6 vertebral body fracture. Resident #51 later expired in the hospital. Law enforcement became involved after being contacted by Resident #51’s family and began collecting information about the incident between the two residents. The facility’s failure to ensure Resident #51 was free from abuse by another resident resulted in actual harm, including the documented head and cervical spine injuries.