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F0600
D

Failure to Protect Resident from Abuse by Visitor

Oakland, California Survey Completed on 05-13-2025

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 family member (FM) of a resident entered a shared room and physically and verbally abused another resident. The FM, who was upset and accused staff of mistreating her sibling, began yelling, throwing objects, and then slapped the other resident in the face. The resident, who had a history of hypertension and epilepsy and was cognitively intact according to a recent BIMS assessment, sustained an abrasion on the left eyelid and complained of pain, which led to an emergency department evaluation. Multiple staff interviews confirmed that the FM was visibly upset, made threats, and accused the resident of stealing a TV remote. The FM physically attacked the resident, holding his arms and slapping him, while also calling him derogatory names. Staff, including a registered nurse and an infection preventionist, attempted to intervene and de-escalate the situation, but the FM continued to yell and refused to leave the room immediately. The resident appeared frightened and asked the FM to go away. Documentation in the resident's medical record, including an eINTERACT Change in Condition Evaluation and interdisciplinary team notes, confirmed the physical injury and the circumstances of the incident. The facility failed to protect the resident from abuse by a visitor, resulting in physical harm and emotional distress.

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