F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse During 1:1 Supervision

Stockton, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident with a known history of intrusive, assaultive, and socially inappropriate behaviors. Resident 1 was admitted with schizoaffective disorder bipolar type, cataract, presbyopia, and anemia. Resident 2 was admitted with schizoaffective disorder bipolar type, violent behavior, and mild neurocognitive disorder with behavioral disturbance. Resident 2 had documented care plans for intrusive behavior, assaultive behavior, combative behavior, and socially inappropriate behavior, including a history of pacing, entering other residents’ rooms, becoming aggressive with redirection, and attempting to strike staff during oral medication administration.

On the night of the incident, Resident 2 was on 1:1 supervision due to sexually and socially inappropriate behavior. CNA 1, who was assigned to provide 1:1 supervision, reported that Resident 2 was restless, agitated, pacing, and repeatedly leaving the room, and described these behaviors as acting weird. CNA 1 attempted redirection, advised Resident 2 to calm down, and encouraged Resident 2 to go back to sleep, but these nonpharmacological interventions were ineffective. CNA 1 stated she asked the nurse to give medication to help with Resident 2’s behavior, but Resident 2 initially refused. Despite ongoing uncontrolled behaviors that did not respond to redirection, medication to manage behavior was not successfully administered before the incident.

At approximately 4 AM, Resident 2 used the bathroom and, upon exiting, walked toward Resident 1’s bed. Resident 2 approached the head of Resident 1’s bed, where Resident 1 was sleeping, and smeared feces on Resident 1’s face. The CNA yelled for help, and nursing staff responded. Progress notes and MAR review confirmed that Ativan by mouth was offered and refused, and Ativan by injection was administered to Resident 2 only after the incident. Multiple licensed nurses and the DON stated that 1:1 supervision required staff to remain within arm’s length or very close proximity to the resident, closely monitor for escalating behaviors, and intervene to prevent the resident from entering another resident’s personal space, and that when nonpharmacological interventions were ineffective, prescribed PRN medication should be administered promptly to prevent escalation. The facility’s policies on management/prevention of assaultive behavior and elder and dependent adult abuse stated that residents have the right to be free from physical abuse and that PRN medication may be offered when nonpharmacological interventions are ineffective, but Resident 1 nonetheless experienced unwanted physical contact with feces from Resident 2.

The physical layout of the room placed Resident 1’s bed (Bed C) near the window and bathroom, with the head of the bed against the wall and the foot of the bed visible from the bathroom exit. Resident 2’s bed was in the middle (Bed B). On the date of the incident, Resident 2 had also been reported to have left paper towels with feces at the nurse’s station on two occasions and had previously sprayed CNAs with a shower hose. Staff interviews confirmed that Resident 2’s behaviors were escalating and that 1:1 supervision was in place for safety and behavior concerns. Despite this, Resident 2 was able to exit the bathroom, cross into Resident 1’s personal space, and smear feces on Resident 1’s face while Resident 1 slept, constituting physical abuse by another resident and a failure to protect Resident 1 from abuse as required by facility policy and regulation.

Staff, including LN 1, LN 2, LN 3, and LN 4, acknowledged that Resident 2’s history of intrusive, anxious, pacing, aggressive, assaultive, and combative behaviors placed Resident 2 at risk for resident-to-resident altercations and that delays in administering ordered behavior-management medications could allow behaviors to escalate and increase safety risks. They also stated that 1:1 supervision required close proximity, continuous observation, and prevention of entry into other residents’ personal space. Nonetheless, during the period of escalating restlessness and agitation, Resident 2’s behavior was not effectively controlled, and the required level of supervision and timely pharmacologic intervention was not achieved before Resident 2 smeared feces on Resident 1’s face. This sequence of events led to the deficiency for failure to protect a resident from physical abuse by another resident.

The facility’s Elder and Dependent Adult Abuse/Suspicion of a Crime policy stated that every resident has the right to be free from physical abuse with resulting physical harm, pain, or mental suffering, and that residents must not be subjected to abuse by anyone, including other residents. The Management/Prevention of Assaultive Behavior policy stated that when licensed staff assess that an individual is not responding to nonpharmacological interventions, PRN medication may be offered per physician order. Despite these policies and the known behavioral history and active 1:1 supervision status of Resident 2, the facility did not prevent Resident 2 from entering Resident 1’s personal space and smearing feces on Resident 1’s face while Resident 1 was sleeping, resulting in the cited deficiency for failure to protect residents from abuse.