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F0600
D

Resident-to-Resident Physical Abuse Resulting in Pain and Emotional Distress

Davis, California Survey Completed on 05-06-2025

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 deficiency occurred when a resident with hemiplegia and no memory impairment was physically abused by another resident with severe memory impairment and a diagnosis of bipolar disorder. Staff, including a CNA, witnessed the second resident striking the first resident multiple times on the hand and face. The incident resulted in the first resident experiencing physical pain, redness on the face, and emotional distress, as documented in progress notes and interviews. The affected resident was observed to be tearful, upset, and uncomfortable following the altercation. The facility's own policy states that each resident has the right to be free from abuse, including physical abuse such as hitting. Multiple staff members, including the CNA, Social Services Director, and DON, acknowledged that the first resident was a victim of physical abuse by another resident. The incident was documented in the SBAR form and progress notes, and the emotional impact on the resident was significant enough to warrant a referral to psychiatry.

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