F0600

G

Failure to Protect Residents From Physical and Verbal Abuse by Roommates

Bement, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by another resident. One resident with cerebral vascular accident, quadriplegia, contractures, anxiety, and total dependence for all ADLs, who is non-verbal but cognitively intact and communicates by yes/no head movements, reported being punched in the stomach by his ambulatory roommate on three separate occasions. Nursing progress notes document that this dependent resident had decreased appetite and an upset stomach in the days preceding disclosure. On one occasion, a CNA brought the resident to a nurse because the resident was afraid to return to his room due to his roommate, and during further evaluation the resident accused the roommate of assaulting him.

The medical record documents that the non-verbal resident indicated his roommate hit him in the stomach with a closed fist on three occasions when the roommate was upset about facility issues such as smoking or leaving the building. The resident reported that the punches hurt and made him feel bad, and that he was afraid of his roommate. The facility’s investigative report and a police incident report confirm that the resident communicated fear of reprisal if the roommate remained in the facility and that the roommate had a prior history of leaving the facility and threatening violence toward staff if they tried to stop him. The roommate’s diagnoses included personality disorder, bipolar disorder, schizoaffective disorder, major recurrent depression, anxiety, stimulant abuse, and cannabis use, and he was ambulatory and made attempts to leave the building without notifying staff. These circumstances show that the facility did not prevent repeated physical abuse of a highly dependent, non-verbal resident by another resident.

The deficiency also includes the facility’s failure to recognize and respond to verbal abuse between roommates as potential abuse. One resident with moderate cognitive impairment and major depressive disorder in remission reported feeling fearful of her former roommate, who was cognitively intact and diagnosed with dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The fearful resident stated that her roommate yelled, cursed, and repeatedly used an expletive toward her about a week prior and that this behavior scared her. A CNA reported that about a week before a later reported incident, staff heard the cognitively intact roommate loudly yelling at the other resident, that the fearful resident was very upset, and that both residents were verbally arguing back and forth before the CNA intervened to de-escalate the situation and then reported it to the Administrator and nurse.

A psychotherapist/LCSW later reported hearing the same verbally aggressive resident call her roommate a derogatory name, after which the residents were separated. The Administrator/Abuse Prevention Coordinator stated that when this verbal altercation was reported, it was viewed as more of a grievance and was not entered on the grievance log, and acknowledged it should have been handled as a potential abuse issue. The facility’s own Abuse Prevention Policy affirms residents’ rights to be free from abuse and defines verbal abuse as the use of disparaging and derogatory language, including saying things to frighten a resident. Despite this policy, the facility did not initially treat the reported verbal aggression and the fearful resident’s statements as potential abuse, contributing to the failure to protect residents from verbal abuse by another resident.