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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

Alameda, California Survey Completed on 04-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with impaired cognition, schizophrenia, and a history of unpredictable and aggressive behavior entered another resident's room late at night and pulled open the curtain around the bed. The resident whose space was invaded, who had mild cognitive impairment and was able to communicate clearly, screamed and asked the intruding resident to leave. When the resident stood up to ask the other to leave, the aggressive resident slapped her on the left side of the face. This incident was witnessed by a roommate, who confirmed the slap and reported that the event disturbed their sleep. The aggressive resident's care plan documented a pattern of physical behavioral symptoms directed toward others, including previous altercations. Facility records and interviews indicated that the aggressive resident's behavior had previously put others at significant risk for injury. The facility's abuse prevention policy states that residents have the right to be free from physical abuse, but the incident demonstrated a failure to protect a resident from physical abuse by another resident.

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