F0607

D

Failure to Separate Roommates After Verbal Altercation Leading to Resident Injury

Bell Gardens, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own policy and procedure titled “Resident-to-Resident Altercations,” which required staff to separate residents involved in an altercation. Two residents, identified as Residents 4 and 5, were roommates and became involved in a verbal altercation on the evening of 1/9/2026 related to personal belongings, specifically cigarettes and a cell phone that Resident 4 had entrusted to Resident 5 while he was at a general acute care hospital. Licensed vocational nurses (LVN 2 and LVN 3) intervened to de-escalate the situation by returning the phone and providing a cigarette, and both residents appeared calm and were left in the same room to sleep. RN 4 was informed of the verbal altercation by LVN 2 and LVN 3 and, upon checking the room and finding both residents sleeping, did not wake them and instead verbally relayed that one of the residents should be moved once they awoke. No room change or separation was implemented at that time.

Resident 4 had a history that included bipolar disorder, COPD, and hypertension, with a Minimum Data Set (MDS) indicating moderately impaired cognitive skills for daily decision-making and use of antipsychotic medication. His History and Physical documented that he had capacity to understand and make decisions. Resident 5’s diagnoses included osteomyelitis of the right ankle and foot, type 2 diabetes mellitus, and acute kidney failure, with an MDS indicating intact cognition and a need for moderate assistance with certain activities of daily living. Despite the facility’s policy requiring separation of residents after an altercation, both residents remained in the same room overnight following the initial verbal conflict.

On the morning of 1/10/2026, a second altercation occurred between the same two residents, again related to the cigarettes that Resident 4 had entrusted to Resident 5. Resident 4 reported that upon readmission from the hospital he discovered that Resident 5 had smoked all of his cigarettes, leading to anger, yelling, and derogatory name-calling. CNA 1 heard yelling from the room, entered, and witnessed Resident 5 stand up and push Resident 4 against the nightstand. CNA 1 called for assistance and separated the residents, then informed RN 3. RN 3 observed that the physical altercation had ended and noted an abrasion above Resident 4’s right eyebrow. Documentation in the Change in Condition note and Skin Assessment on 1/10/2026 confirmed that Resident 4 sustained an abrasion measuring 1.5 cm by 1 cm above his right eyebrow as a result of being pushed into the nightstand. During interviews, RN 2, the Social Services Director, the Director of Nursing, and the Administrator all acknowledged that the residents were not separated after the initial verbal altercation and that a room change should have been considered or conducted, consistent with the facility’s policy, to prevent further altercations.