F0609

D

Failure to Report and Document Resident-to-Resident Abuse Incident

Phoenix, Arizona Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The facility failed to timely report and document a resident-to-resident abuse incident involving intimidation and threats, as required by its abuse policy and staff expectations. One resident, identified as having mild neurocognitive disorder, major depressive disorder, and a history of psychosis-related behaviors including verbal aggression, intrusiveness, and inappropriate sexual advances, had multiple prior behavior notes documenting verbal aggression and threats toward peers and staff. Another resident, diagnosed with vascular dementia and severe cognitive impairment, had a care plan identifying behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Despite these known behavioral risks, there was no documentation in either resident’s clinical record regarding the specific resident-to-resident incident that occurred on January 20, 2026.

Staff interviews revealed that within the week prior to the survey, the first resident created a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” An LPN reported witnessing the resident holding the pretend cardboard gun and telling the other resident to go to sleep or he would shoot him, and stated that the second resident appeared intimidated and subsequently 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, then returned it to the resident because she was afraid of what he might do to her. She further stated that she reported the incident to the unit manager, was instructed to write a statement on paper, and requested that the unit manager take the cardboard gun from the resident.

Despite this report, the DON stated she was unaware of any recent abuse incident between these two residents and only knew that the first resident had been verbally aggressive to staff over a recent weekend. The unit manager initially stated that she had not reported anything recently and only learned shortly before her interview that the resident had made a cardboard gun and was playing with staff and the other resident; she stated she did not recall the incident being reported to her and did not investigate or report it. Review of the facility’s self-reports, grievances, and investigations for the prior four months showed no reported incidents or grievances, and review of the State Agency complaint database showed no evidence that the incident had been reported. This inaction occurred despite the facility’s written Abuse Guidelines policy, which required immediate reporting of suspected abuse, including intimidation, to facility management, immediate notification of the administrator, and prompt notification of state agencies, the ombudsman, the resident representative, APS, and the physician, as well as documentation in incident reports and progress notes.

The facility’s own policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and explicitly stated that resident abuse by anyone, including other residents, would not be condoned. Staff interviews confirmed that they understood reportable incidents to include physical, verbal, and resident-to-resident abuse, and that such incidents were to be reported immediately to the DON, administrator, or designated supervisor, and documented in the clinical record. Nonetheless, there was no evidence of progress notes, incident reports, or external notifications related to the cardboard gun incident, and the DON and unit manager both denied having reported or investigated it. This lack of reporting and documentation of a witnessed resident-to-resident abuse incident constituted the deficiency identified by the surveyors.