F0607

D

Failure to Implement Abuse Policy After Resident-to-Resident Threat with Cardboard Gun

Phoenix, Arizona Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse policy following a resident-to-resident abuse incident involving two residents. The facility’s own "Abuse Guidelines" policy requires that any suspected or actual abuse, including intimidation and resident-to-resident abuse, be immediately reported to facility management, that the DON and administrator be notified, that the resident be examined by a physician or licensed nurse with findings documented in the medical record, and that an unusual occurrence form and written witness statements be completed with an immediate investigation. Despite these requirements, there was no documentation in either resident’s clinical record of the alleged abuse incident that occurred on January 20, 2026, and the DON reported having no knowledge of any recent abuse incident between the two residents.

One of the residents involved, identified as Resident #89, had a history of behavioral issues documented in the clinical record. Diagnoses included mild neurocognitive disorder, major depressive disorder, and other chronic medical conditions. Care plans noted behavior problems related to psychosis, including delusions, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances, with interventions to protect the rights and safety of others. Behavior notes over several weeks documented repeated episodes of verbal aggression, threats toward staff and peers, and at least one incident where he physically placed his hands on another resident’s arms during an argument. However, there was no behavior note or other documentation regarding the cardboard gun incident on January 20, 2026, despite staff describing it as resident-to-resident abuse.

The other resident, identified as Resident #78, had vascular dementia with severe cognitive impairment (BIMS score of 03) and multiple chronic conditions. His care plan documented behavioral symptoms related to dementia, including physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Staff interviews revealed that within the week prior to the survey, Resident #89 created a cardboard gun, entered Resident #78’s room, and threatened him, telling him to be quiet or he would "teach [him] a lesson" and stating "go to sleep, or I am going to shoot you." Staff witnesses, including a CNA and an LPN, described the incident as resident-to-resident emotional abuse and reported that Resident #78 appeared intimidated and frightened afterward, staying in bed and not wanting to do anything. The LPN who witnessed the event stated she reported the incident to the unit manager and was instructed to write a statement, but the unit manager later stated she did not recall the incident being reported and did not investigate it. The facility’s records showed no self-reports, grievances, or investigations for the prior four months, and there was no clinical documentation or formal reporting of this abuse incident as required by the facility’s abuse policy.

Interviews with multiple staff members further demonstrated the breakdown in implementing the abuse policy. The CNA described Resident #89 as aggressive and intimidating, especially around women, and confirmed that the cardboard gun incident occurred and that he considered it resident-to-resident abuse. The LPN who witnessed the incident stated that abuse incidents should be documented in progress notes and reported immediately to the DON or administrator, and that she did report the event to the unit manager and requested that the cardboard gun be taken away. The DON stated that allegations of abuse must be documented in the clinical record and reported to state agencies within two hours, and that resident-to-resident verbal or physical abuse is reportable, yet she was unaware of the incident. The unit manager stated that abuse allegations should be reported immediately and documented, but she denied having recently reported anything and said she only learned of the cardboard gun situation minutes before her interview and did not investigate it. This combination of absent documentation, lack of reporting to the DON and state agencies, and failure to initiate an investigation after a witnessed resident-to-resident abuse incident constitutes the core deficiency in implementing the facility’s abuse policy.