F0600

J

Failure to Prevent and Address Resident-to-Resident Physical Abuse

Windsor, Colorado Survey Completed on 07-15-2025

Penalty

No penalty information released

Summary

The facility failed to protect cognitively impaired residents from repeated incidents of physical abuse and attempted abuse by another resident with a history of severe cognitive loss and psychiatric diagnoses. Multiple altercations occurred involving this resident, who exhibited escalating physically aggressive behaviors toward several other residents, all of whom also had significant cognitive impairments. These incidents included attempts to harm a roommate by threatening with oxygen tubing and placing a bedside table on the roommate's chest, as well as attempts to harm other residents by using objects such as a walker and by direct physical aggression, resulting in at least one resident falling to the floor.

Despite these events, the facility did not conduct timely or comprehensive interdisciplinary team (IDT) reviews or clinical assessments to address the changes in the resident's behavior. There was no evidence that the facility updated care plans or implemented effective interventions to prevent recurrence after the initial incidents. The facility also failed to separate residents known to have conflicts, and did not update behavior monitoring orders or care plans to reflect new aggressive behaviors. Staff interviews revealed a lack of communication and training regarding resident-specific behaviors and interventions, particularly among contract and agency staff, leading to further risk of harm.

Additional incidents of resident-to-resident altercations occurred on other units, with no timely evidence of interventions to prevent repeat abuse. The facility's documentation and monitoring practices were inconsistent, and staff were not always aware of or following care plan interventions. The lack of prompt and effective action to address and prevent aggressive behaviors resulted in repeated exposure of vulnerable residents to potential and actual harm.

Removal Plan

• Initiate one-to-one staff supervision for Resident #4 and maintain until survey exit.
• Provide all staff education on prevention and de-escalation of behaviors with Resident #4.
• Initiate resident abuse education for staff by the DON; complete at the beginning of each shift until 100% of staff are educated; provide ongoing education prior to the start of shift for all contracted staff.
• Create an additional binder at the nurses’ station to provide education to agency staff on abuse expectations and procedures.
• Initiate education with staff on all residents’ plan of care updates.
• Initiate a binder for resident-specific behaviors, identified triggers, and interventions and place it at every nurses’ station.
• Review and update Resident #4’s comprehensive care plan and abbreviated care plan with up-to-date triggers and non-pharmacological interventions.
• Complete a facility-wide audit for all residents with a history of verbal and/or physical aggression; update care plans with person-centered interventions including triggers and non-pharmacological interventions.
• Have the DON or designee complete audits on three random residents three times per week for twelve consecutive weeks, including observation of resident interactions/roommate situations and staff interviews to confirm staff awareness of resident behaviors, triggers, and interventions.