F0600

E

Failure to Protect Cognitively Impaired Residents From Physical Abuse by Resident and Visitor

Scottsdale, Arizona Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect three cognitively impaired residents from physical abuse by another resident and by a family member. For the first incident, two male residents with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, depression, anxiety, and mood disorders, were involved in a resident‑to‑resident altercation in the dining room. One resident, seated in a wheelchair, was observed by an LPN and the activities assistant being repeatedly hit with full force by another resident who was standing over him. Staff ran to separate the residents. Initial skin assessment documented no injury to the resident in the wheelchair, but a later change in condition evaluation identified an injury described as a knot on the left side of his forehead. The resident who initiated the hitting was found to have discoloration and hematomas on the knuckles of his right hand.

The facility’s own care plans and assessments documented that both residents had severe cognitive impairment, with BIMS scores of 7 and 5, and that one resident had a known behavior problem related to taking things and flushing them down the toilet. The care plan for that resident included interventions such as anticipating and meeting needs, intervening as necessary to protect the rights and safety of others, diverting attention, and removing the resident from situations as needed. Following the altercation, a new care plan focus was added for psychosocial well‑being problems related to resident‑to‑resident altercations, with interventions such as 72‑hour observation and removing residents to a calm, safe environment when conflict arises. Staff interviews confirmed that several staff members witnessed the altercation, that the resident who hit the other stated someone was trying to get into his backside, and that the other resident denied doing anything. Both residents later denied or could not consistently report the altercation when interviewed by surveyors.

The second incident involved a visitor‑to‑resident altercation between a severely cognitively impaired resident with dementia, Parkinsonism, hypertension, postconcussional syndrome, and a history of falls, and her husband. A CNA reported to a nurse that he heard the husband and the resident arguing loudly in another language and that the husband physically abused the resident in the day room. Another CNA later reported that her coworker had told her she witnessed the husband kicking the resident very hard when the resident refused to take medication, and that the resident was crying afterward and unable to express herself because she spoke Korean. Additional staff interviews corroborated that the husband became frustrated when assisting the resident with medications, eating, and ADLs, had yelled at and physically touched her in those situations, and that he had kicked her when she spat out medication. The DON acknowledged that the husband’s actions, including kicking the resident, constituted physical abuse. A care plan focus for psychosocial well‑being related to dementia and the husband’s behavior documented that he became frustrated and had yelled and physically touched the resident when trying to help her, and that the resident did better when he was present, with interventions including supervised visits in public places only and removing residents to a calm, safe environment when conflict arises.

Across both incidents, staff interviews showed that personnel were generally aware of different types of abuse and the expectation to separate involved parties and report incidents to the nurse, DON, or administrator. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention stated that residents have the right to be free from abuse, including physical abuse. Despite this, the survey findings concluded that the facility failed to protect the rights of three residents to be free from physical abuse by other residents and family members, based on the resident‑to‑resident altercation in the dining room and the visitor‑to‑resident altercation involving the resident’s husband physically abusing her.