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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision

Grand Bay, Alabama Survey Completed on 06-13-2025

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

The facility failed to protect two residents from physical abuse when staff did not provide adequate supervision or timely intervention during an altercation. On the morning of the incident, one resident, who had a history of behavioral issues and severe cognitive impairment, was reported to be agitated and was seated in a gerichair outside their room near the nursing station. Another resident, also with severe cognitive impairment and a history of agitation, was being escorted by staff in a wheelchair to the same area. As the second resident passed by, the first resident began yelling obscenities and then struck the second resident on the arm. The second resident retaliated by hitting back, resulting in both residents striking each other multiple times before staff intervened and separated them. The care plan for the first resident specifically indicated that staff should promptly intervene when acute behaviors are noted to reduce the risk of escalation. Despite this, staff did not act quickly enough to prevent the physical altercation. Witness statements from both a CNA and an RN confirmed that the first resident was agitated and verbally aggressive prior to the incident, and that staff were present in the area but did not remove or redirect the residents before the situation escalated to physical abuse. The RN acknowledged that the incident could have been prevented by not positioning the residents near each other or by removing the agitated resident from the area as soon as the behavior began. Both residents were assessed after the incident, and one was noted to have purplish bruising. The facility's policy defines abuse to include resident-to-resident altercations, and both the DON and the administrator identified the incident as physical abuse. The deficiency was cited as a result of the facility's failure to follow the care plan and to provide adequate supervision and intervention to prevent abuse between residents with known behavioral risks.

See complete original report
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