F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse by Known Aggressive Resident

Tucson, Arizona Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. The alleged victim, resident #911, had diagnoses including aphasia, hemiplegia, hemiparesis, dementia, major depressive disorder, and anxiety disorder, and resided on a secured unit due to vascular dementia. A recent MDS showed short- and long-term memory problems and moderate cognitive impairment in daily decision-making, with documented physical and verbal behavioral symptoms and wandering. Care plans identified risks for psychosocial well-being problems, cognitive problems, and abuse related to dementia, with interventions such as emotional support, calm reassurance, increased 1:1 activities, and monitoring for mood or behavior changes after incidents.

On the date of the incident, an incident report and nursing documentation described a resident-to-resident altercation in a hallway in which another resident, identified as the occupant of room [ROOM NUMBER]B (resident #999), suddenly rose from his wheelchair and struck resident #911 twice on the nose with a closed fist. Resident #911 sustained a small, open, bleeding area across the bridge of the nose, reported pain at 5/10, and later developed bruising around the right eye. A wound care note and skin assessment documented an abrasion on the bridge of the nose, and subsequent nursing notes confirmed ongoing bruising and healing of the nasal abrasion. Social Services documented that resident #911, who had limited verbal communication and primarily responded by nodding or brief statements, recalled the incident and stated he was okay, appearing calm and without observable distress.

The alleged perpetrator, resident #999, had diagnoses including dementia, anxiety disorder, schizophrenia, psychosis, and major depressive disorder, and had been placed on a secured unit due to psychosis and schizophrenia with verbal and physical aggression toward staff. Prior documentation showed a pattern of physical aggression: a nursing note from October 28, 2025 recorded that he hit another resident on the nose after claiming his wheelchair had been kicked, and a note from November 1, 2025 recorded that he hit a CNA’s hand, was verbally aggressive, and threw a bedside commode. These incidents were not reflected in care plans with specific interventions to prevent further incidents at the time they occurred. A behavioral care plan initiated later documented combative and aggressive behaviors such as yelling, hitting, and grabbing, with general interventions to monitor behaviors and protect others’ rights and safety. On the date of the abuse incident involving resident #911, an incident report and nursing notes documented that resident #999 approached resident #911 and punched him twice on the nose, later stating he did so because the other resident touched his girlfriend’s hand, although the girlfriend was not present in the hallway. The facility’s investigation, including witness and resident interviews, concluded that the allegation of abuse was verified. Facility policies on Abuse and Neglect and on Accident Hazards/Supervision/Devices required assessment, care planning, monitoring, identification of residents likely to be involved in altercations, and implementation of interventions to minimize resident-to-resident altercations, which were not effectively carried out for resident #999 despite his known aggressive history.