F0600

D

Failure to Recognize, Document, and Report Resident-to-Resident Abuse Involving Threats with a Cardboard Gun

Phoenix, Arizona Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to recognize, document, and report the incident as required by policy. One resident had a documented history of behavioral problems related to psychosis, including delusions, refusing care, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances toward females. Care plans identified these behaviors and included an intervention to protect the rights and safety of others. Behavior progress notes over several weeks documented multiple episodes of verbal aggression, threats toward peers and staff, and at least one incident where the resident physically placed his hands on another resident’s arms while attempting to redirect him, leading to an argument that required staff separation. Despite this pattern of escalating behaviors, there was no documentation in the clinical record regarding a later resident-to-resident incident that occurred on January 20, 2026.

The other resident involved had vascular dementia with severe cognitive impairment, as evidenced by a BIMS score of 03, and a care plan that identified behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and educating the resident on appropriate behaviors when on the patio with peers. The clinical record for this resident also lacked any documentation of the resident-to-resident incident on January 20, 2026. When surveyors requested the facility’s self-reports, grievances, and investigations for the prior four months, the facility reported that there had been no incidents or grievances during that period, despite staff accounts of a serious resident-to-resident event.

Multiple staff interviews described the unreported incident and the facility’s failure to follow its abuse policy. A CNA stated that the aggressive resident had a pattern of trying to intimidate people, especially when women were present, and reported that within the prior week he made a cardboard gun, covered his face with a bandana, entered the cognitively impaired resident’s room, and threatened to “teach [him] a lesson” if he did not be quiet. An LPN reported witnessing the same event, stating that the resident held a pretend cardboard gun, told the other resident to go to sleep or he would shoot him, and that the threatened resident appeared intimidated and later stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, saw it had been colored to look more realistic, but returned it to the resident because she was afraid of what he might do. She reported the incident to the unit manager and was told to write a statement, but the DON later stated she was unaware of any such abuse incident, and the unit manager stated she did not recall the incident being reported and had not investigated it. The facility’s abuse policy required immediate reporting of suspected abuse to the DON and administrator and documentation of incidents, but there was no evidence of documentation, self-reporting, or investigation of this resident-to-resident abuse.

The DON stated that allegations of abuse were expected to be documented in an incident report and progress note and reported within two hours to applicable state agencies, physicians, case managers, and family, and that resident-to-resident physical or verbal abuse was considered reportable. The unit manager similarly stated that staff were expected to document all progress notes, including incidents of abuse or allegations, and that allegations should be reported immediately, but no longer than two hours, to the DON. Despite these stated expectations and the written Abuse Guidelines policy defining abuse as willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and requiring immediate reporting of suspected abuse, the incident involving the cardboard gun and threats was not documented in either resident’s clinical record, not entered as a self-report or grievance, and not brought to the DON for investigation. This failure to follow policy and to recognize and report the resident-to-resident intimidation and threats constituted the identified deficiency.