Failure to Protect Cognitively Impaired Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and protection from physical abuse for one resident with severe cognitive impairment and a history of trauma, including sexual and other forms of abuse. The resident had diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, and vascular dementia, and a care plan problem category of mood state documenting major depressive disorder and anxiety. The resident’s Minimum Data Set showed a BIMS score of 4, indicating severe cognitive impairment. Despite this vulnerability and documented history of trauma, the resident remained in a shared room with another cognitively impaired resident who later became physically aggressive. On the date of the incident, the cognitively impaired roommate approached the resident while she was going through her closet and accused her of taking her boyfriend. A verbal argument ensued, during which the resident yelled that she did not want the boyfriend. The roommate then grabbed the resident’s hand and bit it, causing an immediately visible bruise. A bystander resident yelled that someone was fighting, prompting CNAs to run to the room. When staff arrived, the residents were already separated, with the injured resident holding her hand and stating that the roommate had bitten her. Staff observed a crescent-shaped, dark purple to almost black bruise on the palmar surface of the resident’s right hand below the fifth finger, resembling a human bite mark, with a blood blister and lipstick noted around the area; the skin was closed and not broken. Interviews and documentation showed that the incident was characterized as a resident-to-resident altercation and physical assault, with both residents marked as interviewable but unable to make informed decisions. The injured resident repeatedly reported that her right hand was hurting, and staff confirmed the presence of a bruise in the shape of a human bite or crescent moon. The facility’s abuse policy stated that the facility actively prohibits resident abuse and that special attention will be given to identifying behavior that increases a resident’s potential for abusing others or being a victim of abuse. Despite this policy and the resident’s known history of trauma and severe cognitive impairment, the facility failed to prevent the physical abuse that occurred when the roommate bit the resident’s hand, resulting in a bruise.
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