Failure to Protect Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. One resident with metabolic encephalopathy and pneumonia due to COVID-19, who had a BIMS score of 12 indicating moderate cognitive impairment, shared a room with another resident diagnosed with spinal stenosis and unspecified dementia, also with a BIMS score of 12. On the evening of the incident, a CNA alerted an LVN that the first resident was in the bathroom with visible facial bleeding. The resident reported that his roommate had hit him in the face after he asked the roommate, who was pacing and talking on a cell phone, to take the call into the hallway so he could rest. When the LVN entered the room, the injured resident had an injury on his forehead and was washing blood from his face, while the roommate was sitting on his bed talking to himself; during the subsequent police investigation, a small drop of blood was noted on the roommate’s hand. Progress notes documented that the resident had lacerations to the right eyebrow and right lower eyelid, with the right eye swollen, red, and bloodshot. The lacerations measured approximately 4 cm by 0.5 cm on the right eyebrow and 2 cm by 0.5 cm on the right lower eyelid. The resident stated that when he tried to talk to his roommate about pacing and phone use, the roommate suddenly raised his arms and made contact with his right eye, causing the injury. An emergency department note recorded that the resident complained of pain in his head, face, and chest, and that he reported being hit in both the face and chest by his roommate. The ED documented contusions to the right maxillary soft tissues and the soft tissue surrounding the right eye and supraorbital ridge, with a discharge diagnosis of injury due to physical assault, contusion of face, and safeguarding concerning adult. These events occurred despite the facility’s written Abuse Prevention Policy, which states that residents have the right to be free from all forms of abuse, including physical abuse, and that the facility prohibits and prevents such abuse.
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