Failure to Protect Resident From Physical Abuse by Aggressive Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The facility’s own policy, revised in October 2022, prohibits mistreatment and abuse and defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Despite this, an incident occurred in which two residents were heard screaming in their shared room, and staff who responded found one resident with blood on the upper and lower lips and later-documented facial injuries, including swelling to the eye, a lump on the cheek, bruising to the face, and lacerations to the lips. The injured resident, who was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs, reported being struck multiple times in the head and face while seated in a wheelchair after refusing a request from the roommate to close the bedroom door. The resident who committed the assault had a documented history of anxiety disorder, delusional disorder, and behavioral issues, including verbal aggression and increased agitation. The care plan for this resident, revised in August 2024, identified behaviors such as verbal aggression and agitation and included interventions for staff to intervene when the resident became agitated, document all behaviors, attempt to identify patterns, and encourage medication compliance. Nursing progress notes in December 2025 and early January 2026 documented an increase in agitation and aggressive behaviors, including repeatedly throwing meal trays on the hallway floor, being non-compliant with redirection and re-education regarding safety, and continued restlessness and agitation with care. A psychiatric evaluation noted ongoing behavior disturbance and non-compliance with medications. A physician’s order dated mid-December 2025 directed staff to monitor and document the aggressive resident’s behaviors and record the number of episodes every shift. However, the January 2026 Treatment Administration Record did not show evidence of behaviors on the date of the physical altercation, despite the documented violent incident that day. During interviews, the aggressive resident admitted to punching the roommate in the face, and the injured resident reported that the roommate had been physically aggressive in the past and that the facility was aware of this history. Staff and facility leadership also acknowledged the resident’s history of aggressive behaviors. The lack of effective monitoring, documentation, and intervention in response to the known behavioral history and physician’s order contributed to the failure to keep the injured resident free from physical abuse.
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