Failure to Protect Roommates From Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse as required by its abuse prevention policy, resulting in two residents experiencing physical abuse. One resident with hemiplegia and hemiparesis following cerebrovascular disease shared a room with another resident diagnosed with schizophrenia, schizoaffective disorder, and major depressive disorder, who was admitted with a history of primarily verbal aggression. During a disagreement in their shared room, the cognitively intact resident with psychiatric diagnoses attempted to adjust the heat on the roommate’s side of the room. The roommate complained that the other resident smelled, after which the aggressive resident made physical contact with the roommate’s leg. The resident with hemiplegia, who had left-sided weakness and could not effectively block the contact, reported being hit first on the leg and later stated it was the arm, and complained of left arm pain, prompting an X-ray. The incident report and interviews documented that the resident with psychiatric diagnoses made physical contact with the roommate, and the facility’s Administrator/Abuse Coordinator and DON concluded that this contact met the facility’s definition of physical abuse. The roommate reacted by striking the aggressive resident with a reacher, causing a minor skin alteration to the aggressor’s nose. A police report characterized the event as simple battery, and social services documented that the aggressive resident required psychiatric evaluation due to aggression toward the roommate and difficulty with redirection. Despite known behavioral issues, lack of physical limitations, poor hygiene, and an intimidating demeanor, the aggressive resident had been placed and maintained as a roommate to a physically impaired resident who could not adequately protect herself from being hit on her weak side, resulting in the abusive contact and associated pain complaint.
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