Failure to Protect Cognitively Intact Resident From Roommate’s Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from abuse by his roommate during a resident-to-resident altercation. One resident with a history of spinal fusion, lower back pain, and major depressive disorder reported to an RN that his roommate physically attacked him after a disagreement about the television volume. Nursing documentation and a skin assessment noted a skin tear on the resident’s left forearm and redness on the right side of his neck, attributed to physical contact/aggression with another resident. The resident later told surveyors that his roommate started strangling him after he asked him to turn down the television volume, and the surveyor observed a quarter-sized scab on his left arm that the resident stated was from the attack. The roommate involved in the altercation was also cognitively intact and had diagnoses including cellulitis of both lower limbs, cerebral palsy, scoliosis, and documented behavioral disturbances such as physical aggression, impulsivity, verbal aggression, and poor impulse control related to a mood disorder. The care plan for this resident identified these behavioral issues and included interventions such as 15-minute checks, reducing noise, dimming lights, and offering choices. Despite these identified risks and planned interventions, the altercation occurred in the shared room, where the roommate allegedly grabbed the first resident around the neck and shoulder area after a verbal disagreement about the television volume. Nursing notes documented that the aggressor resident reported being punched in the face and then reacting by grabbing the other resident’s neck and shoulder, and that he had a minimal raised area on the left cheekbone without discoloration or pain. Interviews with staff and leadership showed uncertainty and inconsistency in recognizing and characterizing the incident as abuse. A CNA reported hearing the resident state that his roommate had choked him and observed scratches on the resident’s left arm, but did not witness the event. The DON initially described the event as a behavioral incident stemming from anger and emotions, expressed uncertainty about who grabbed whom, and stated that she did not initially consider it abuse because she viewed abuse as an intentional act, later acknowledging that the situation could probably be abuse. The Administrator described the event as a very aggressive altercation in which the roommate went under the curtain, was very angry, and went after the resident’s neck with both hands, and categorized the incident as abuse toward the resident. The facility’s abuse and neglect policy defined abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, and the facility’s own 5-day report ultimately verified the allegation of resident-to-resident abuse.
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