F0610

D

Failure to Investigate Alleged 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 investigate and document an alleged incident of resident-to-resident abuse involving two residents. One resident had a history of behavioral issues, including psychosis-related behaviors, verbal aggression, intrusiveness, and inappropriate sexual advances, with care plan interventions to protect the rights and safety of others. Behavior notes over several weeks documented multiple episodes of verbal aggression, threats toward peers, and menacing behavior toward staff, including threatening language and attempts to put hands on another resident. Despite this pattern, there was no documentation in the clinical record regarding a specific resident-to-resident incident that occurred on January 20, 2026.

The other resident involved had vascular dementia with severe cognitive impairment, as indicated by a BIMS score of 03, and a care plan identifying behavioral symptoms such as physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and education on appropriate behaviors. This resident’s MDS also showed frequent verbal behaviors. However, similar to the first resident, there was no documentation in this resident’s clinical record regarding the alleged resident-to-resident incident on January 20, 2026.

Staff interviews revealed that a CNA described the first resident as aggressive and intimidating, particularly around women, and reported that within the prior week the resident made 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.” The CNA stated that staff removed the resident from the room and that he considered the event resident-to-resident abuse, and that two nurses present reported it to their supervisor. An LPN separately reported witnessing an incident in which the same resident entered the other resident’s room with a cardboard gun and threatened to shoot him if he did not quiet down, stating, “go to sleep, or I am going to shoot you,” and that the other resident felt intimidated. This LPN reported the incident to the unit manager and was instructed to write a statement, but did not know if it was reported further or investigated. The DON, who is responsible for abuse coordination, investigation, and reporting, stated she was unaware of any recent abuse incident between these residents, and the unit manager stated she did not recall the incident being reported to her and did not investigate the cardboard gun incident. Review of facility records showed no self-reports, grievances, or investigations for the prior four months, and the facility’s Abuse Guidelines policy required immediate reporting, documentation, examination, and investigation of suspected abuse, including resident-to-resident abuse, which did not occur in this case.

The facility’s Abuse Guidelines policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and stated that the facility would not condone abuse by anyone, including other residents. The policy required employees, consultants, and physicians to immediately report suspected abuse to the DON or, in her absence, to the nurse supervisor, and required immediate notification of the administrator, state licensing agency, ombudsman, resident representative, adult protective services, and the resident’s physician when an allegation or suspected case of mistreatment or abuse was reported. It further required that a physician or licensed nurse immediately examine the resident, record findings in the medical record, complete an unusual occurrence form with written witness statements, and conduct an immediate investigation with a copy provided to the administrator. Despite these policy requirements and staff accounts of a threatening resident-to-resident interaction involving a cardboard gun and verbal threats, there was no evidence that the incident was documented in either resident’s clinical record, reported to the DON or administrator, or investigated in accordance with facility policy.