Failure to Protect Resident from Roommate’s Violent Assault Results in Broken Finger at Southpoint Nursing & Rehab Center

The Illinois Department of Health has cited and fined Southpoint Nursing & Rehab Center when they failed to protect a cognitively intact resident from a roommate with severe dementia who had a documented history of wandering, confusion, and aggressive behaviors. The assault resulted in the victim suffering multiple injuries including a fractured finger, shoulder deformity, and facial bruising.

The incident involved two residents sharing a room at the nursing facility. One resident had severe cognitive impairment with a Brief Interview Mental Status (BIMS) score of 3, indicating severe impairment. He had diagnoses including dementia, metabolic encephalopathy, and psychoactive substance abuse. His care plan noted that he “displays behavioral symptoms related to severe mental illness” with interventions including “Intervene when any inappropriate behavior is observed” and “Refer resident to consulting psychiatrist for a psychiatric evaluation as warranted.”

The other resident was cognitively intact with a BIMS score of 13 and had a care plan indicating that his “medical diagnosis may increase his susceptibility to abuse/neglect.” His interventions included “observe resident for signs of fear and insecurity during delivery of care” and “Assure the resident that staff are available to help, and department heads maintain an open-door policy.”

Progress notes for the resident with dementia documented escalating behavioral issues. Several weeks before the assault, notes indicated: “Resident wandering down hallway and went into another resident’s room. When staff asked resident to come out he became verbally aggressive and began yelling and cursing at staff that this was his house.” A few days later, another note stated: “Resident confused, leaves room and goes into other resident’s rooms walking about the hallway asking where is his room. Resident needs constant redirection.”

Despite these documented behaviors, the facility appeared to take insufficient action to protect other residents. When interviewed, the Social Worker described the resident with dementia as “just a wanderer, he was confused,” minimizing the seriousness of his behaviors.

On the day of the assault, a family member came to visit the resident with dementia. When the family member entered the room, she found the confused resident sitting in his roommate’s wheelchair. The roommate was sitting on the side of his bed leaning forward. When the family member asked if the roommate was alright, he informed her that the resident with dementia “had just jumped on him.” The family member attempted to speak with the resident with dementia, who became aggressive and defensive, prompting her to call for staff assistance.

When staff arrived and separated the residents, they observed the victim with “right 5th digit and shoulder deformity, and right eye discoloration” while the aggressive resident had a “scratch to left forehead.” Both residents were transferred to the hospital for further evaluation and treatment.

The victim later explained what happened: “I was assaulted in August, and I broke my little finger on my left hand. He asked me what was I doing in his house and before I could understand what he was saying to me, he swung at me. He said everything in here belonged to him.” Most concerning, the victim stated that he had been threatened for “about 2 weeks” prior to the assault, yet there was no documentation of these threats in the progress notes, suggesting a significant gap in monitoring and communication among staff.

Hospital examination confirmed that the victim suffered a “closed displaced fracture of proximal phalanx of left little finger.” The resident with dementia never returned to the facility after being sent to the hospital with petition paperwork for psychological evaluation.

The facility’s abuse prevention program states that “it is the policy of this facility to prevent resident abuse” and includes prevention measures such as “Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility’s concern/grievance procedure” and “Staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict.”

Despite these policies and the documented history of the resident with dementia wandering into other residents’ rooms and becoming verbally aggressive when redirected, the facility failed to implement effective interventions to protect his roommate from assault. The victim’s report that threats had been occurring for about two weeks prior to the assault suggests a serious failure in the facility’s monitoring and communication systems.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.