Failure to Protect Residents From Physical Abuse by Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, as evidenced by two substantiated or suspected resident‑to‑resident physical abuse incidents. In the first incident, a resident in a wheelchair (R1) was struck in the face by another resident (R2). Multiple CNAs reported that R1 had papers in her hand that R2 was trying to retrieve, and that R2 then punched or swung and hit R1 in the right side of the face with a closed fist. The nurse on duty heard staff at the nurses’ station saying, “don’t hit her! He hit her!” and, upon assessment, observed a red mark on the right side of R1’s face near her temple and hairline. R1 later reported being hit in the face by a male person, appeared anxious with shaking hands, and described the event as scary. In the second incident, the facility failed to ensure that a cognitively impaired resident (R3), who had a care plan identifying him as at risk for abuse related to behavior problems and dementia, was free from potential physical abuse by his roommate (R4), who also had dementia and resided on the Memory Care unit. A CNA (V13) reported that around midnight R4 repeatedly complained that R3 was keeping him awake and stated that someone needed to keep R3 quiet. Later, around 5:00 AM, V13 observed R4 standing over R3’s bed, heard R4 say that R3 had kept him up all night making noises and that he should hit him, and then found blood around R3’s nose. V13 believed R4 had hit R3 and informed the LPN, who documented discoloration to the bridge of R3’s nose and later a bloody nose that was cleaned and assessed. Subsequent observations by other staff and R3’s wife further documented unexplained facial injuries consistent with trauma. Another CNA (V16) saw R3 shortly after coming on shift and noted bruising to the bridge of his nose, a split lip, and a runny, somewhat bloody nose, and reported being told by V13 that R4 had been standing over R3 and threatening to “kick his ass.” The day‑shift LPN (V17) documented a full body assessment with bruising to the bridge of R3’s nose and right temporal area, while the Administrator and Social Services Assistant both acknowledged bruising and blood on linens without a clear reason for the injury. R3’s wife was informed only that R3’s nose was bleeding and was told they thought he had bumped into something, but she observed a red mark across the bridge and right side of his nose and questioned whether someone had done something to him. These events demonstrate that the facility did not ensure residents were free from physical abuse as required by its Abuse Prevention Program Policy, which defines abuse as any physical injury inflicted upon a resident other than by accidental means, including hitting.
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