F0600

E

Failure to Prevent Resident-to-Resident Physical Abuse Between Roommates

New London, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse by allowing two residents with known behavioral issues to be placed together as roommates, which led to a physical altercation. Resident #15 had diagnoses including vascular dementia with behaviors, schizophrenia, and paranoid personality disorder, with a care plan noting potential for behaviors related to dementia, paranoia, delusions, a history of physical aggression, and a prior resident-to-resident altercation. Resident #40 had diagnoses including unspecified dementia, bipolar II disorder, and anxiety, with a care plan identifying risk for mood and behavioral issues such as rummaging, anger, yelling at staff, increased delusions, and confusion. Despite these documented behavioral risks, the residents were roomed together.

Prior documentation showed that Resident #15 had a past reportable event involving an alleged altercation with a roommate, where words were exchanged and there was an allegation that Resident #15 grabbed the roommate’s arm, though both residents later denied physical contact and no injuries were found. Nursing and psychiatry notes following that earlier event did not identify ongoing resident-to-resident altercations, and subsequent notes up to the time of the later incident did not document further altercations. However, the care plan for Resident #15 continued to reflect a history of physical aggression and a prior resident-to-resident altercation.

On the date of the cited incident, Resident #40 reported to a nurse aide that Resident #15 grabbed them around the neck after Resident #40 adjusted the room thermostat. Resident #15 admitted to putting hands on Resident #40 and justified the action by stating that the other resident had a foul mouth and deserved it. A roommate witness reported seeing Resident #15 place hands on Resident #40’s shoulders and confirmed that an altercation occurred. Staff interviews described Resident #40 as someone who could get mad, loud, and unpleasant with others and as having a feisty personality, and Resident #15, usually quiet, was identified as the aggressor who grabbed Resident #40’s neck during a disagreement over room temperature. The facility’s abuse prohibition policy required a zero-tolerance environment free from abuse, but the placement of these two residents together, despite known behavioral histories and personality incompatibility, led to a physical abuse incident in which Resident #15 grabbed Resident #40 around the neck.