A 62-year-old resident (Resident 1) at a Washington DC nursing home was charged with bludgeoning to death his 80-year-old roommate (Resident 2) with a metal bed rail, according to police and court documents. Police said the attack occurred February 21, 2022, in a fourth-floor room at the facility. Resident 2 died March 20 at a hospice center in Maryland. His death was ruled a homicide from complications of blunt force trauma.
Resident 1 was then taken into custody and charged with second-degree murder. Court documents say Resident 1 told police that Resident 2 attacked him as he slept, and he defended himself. But police said they found only Resident 2ās blood on the removable bed rail. Two other residents in the room told police they had no knowledge of an attack.
In the affidavit, police described Resident 2 as a frail, thin man who used a walker, and they quoted a nurse saying it would be a struggle for him to remove a guardrail. Police said a nurse found Resident 2 ā described as the only resident in the room who needed assistance with daily tasks ā on the floor, his face bloodied.
Police said in their affidavit that facility managers began an internal review after the incident occurred, but the documentāÆdid not revealāÆany conclusions. According to court records, Resident 1 is facing two charges of assault with a dangerous weapon stemming from the stabbings of two peopleāÆin a similar incident at a Washington DC group home in 2019. The victims, one stabbed in the chest, the other in the neck, survived.
Resident 1 pleaded not guilty in the stabbing case, and court records show he was ordered to a psychiatric institution after his arrest in that case. Those records show he was released to a group home last August. It was not clear when he went to the nursing home.
Issue:
Failure to prevent a resident from attacking another resident and failure to perform a Preadmission Screening and Resident Review (PASARR) to accurately assess a residentās risk for aggressive behavior or provide adequate monitoring and services, may result in citations for immediate jeopardy and provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures for accurately assessing residents before and after admission for the risk of aggressive behavior and for ensuring adequate supervision and appropriate room assignment are provided based on their history and current status.
- Train staff about the risk for aggressive behavior by any resident and their responsibility to monitor and note changes or patterns of behavior that may indicate increasing aggression. Also train staff on behavioral health protocols and the importance of reporting distressing behaviors immediately to a supervisor. Teach the reporting process, including how to access the Hotline if anonymous reporting is preferred. Document that these trainings occurred and file the signed documents in each employeeās education file.
- Periodically audit the risk assessments of residents with histories of aggressive behaviors to determine if they are being monitored and if changes are being noted on their care plans. Also audit to ensure that all staff are knowledgeable of behaviors that should be reported immediately to a supervisor, and the process for reporting.
