F0600

D

Failure to Protect Resident From Physical Abuse by Another Resident

North Hollywood, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with functional quadriplegia, multiple sclerosis, optic atrophy, and major depressive disorder, who was cognitively intact but fully dependent on staff for all ADLs, reported being struck on the top of the head by another resident while positioned in a hallway near the smoking patio entrance and dining room. This resident used a specialized wheelchair operated by blowing air to move and could not move his arms or legs. A change of condition note documented that he was monitored for potential pain and emotional distress related to a claimed physical altercation and that he reported acute pain of 1 out of 10 on the top of his scalp.

The other resident involved had intact cognition, required partial to moderate assistance with ADLs and mobility, and used a wheelchair. According to this resident’s own statements documented in an SBAR and interviews, he became upset when he perceived that the quadriplegic resident’s wheelchair was blocking his path in the hallway. He reported lifting his own wheelchair to pass, placing it over the other resident’s legs, and then, after an exchange in which he stated the other resident called him a “Nazi,” he retrieved a wooden back scratcher he had brought from home and “popped” the other resident on the head three to four times, clarifying that “popped” meant he hit the resident’s head. In another account documented by staff, he initially claimed to have made contact with the wheelchair headrest, but later confirmed in interview that he hit the top of the other resident’s head, not the wheelchair.

A third cognitively intact resident witnessed the incident and reported seeing the quadriplegic resident accidentally bump the other resident’s wheelchair with his powered wheelchair. The witness stated that the other resident then stood up, moved his wheelchair past, grabbed what appeared to be a wooden back scratcher, and hit the quadriplegic resident on the top of the head. The witness emphasized that the quadriplegic resident could not move his arms or legs and that any contact from his wheelchair would have been accidental due to the way it is operated. The quadriplegic resident later clarified in a follow-up interview that he had been wearing a hat at the time, that he was hit on the top of his head with a wooden back scratcher rather than a wheelchair, and that although it did not hurt much because of the hat, he knew something had hit him. The facility’s own abuse prevention policy stated that it does not condone any form of resident abuse and that reports of abuse are to be promptly reported and thoroughly investigated, yet the described events show that one resident willfully struck another resident on the head with an object while both were under the facility’s care, constituting physical abuse.

Interviews with nursing leadership and staff confirmed that an altercation occurred between the two residents in the hallway between the smoking area and activity/dining room, that the mobile resident lifted his wheelchair over the quadriplegic resident’s legs, felt that the other resident’s wheelchair had touched him, and then turned around and hit the quadriplegic resident with the wooden back scratcher. The quadriplegic resident did not immediately report the incident, and staff became aware only after the mobile resident reported it to the Administrator the following day. A skin check revealed no redness, and the quadriplegic resident initially reported that being hit did not hurt because of his hat, though he later reported minimal pain and was monitored for pain and emotional distress. Despite the absence of significant physical injury, the act of intentionally striking another resident with an object, as corroborated by the involved resident’s own admissions and a witness account, demonstrates that the facility failed to ensure the resident’s right to be free from physical abuse while in its care.