F0600

D

Failure to Intervene on Verbal Threats Resulting in Resident-to-Resident Physical Abuse

Redding, 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 and to follow its own crisis intervention and reporting policies. The facility’s Crisis Intervention Program required staff to recognize early warning signs of crisis, such as changes in behavior, mood, or thinking, and to provide early intervention when a resident exhibited increased acting-out behaviors. The CNA job description required CNAs to immediately report all changes, including agitation, to the Shift Coordinator (SC). On the day of the incident, a CNA heard one resident yelling, “I’m going to kill you,” but did not enter the room to assess the situation, ensure safety, or investigate what was happening, and did not effectively report this change in behavior to nursing staff or the SC.

The resident who was later physically abused (Resident 1) had a history of schizoaffective disorder, bipolar type, and was conserved. An Annual MDS indicated this resident had delusions, verbal behavioral symptoms directed toward others, intruded on others’ privacy and activities, and significantly disrupted the care or living environment of others. Staff interviews confirmed that this resident had delusions involving being married to Elvis and yelling about wanting to kill a woman she believed was after her husband. However, review of progress notes from 5/5/25 through 12/25/25 showed no CNA documentation that any CNA had witnessed or reported verbal death threats during these recurring delusions.

The resident who committed the physical abuse (Resident 2) was also conserved and had diagnoses of schizophrenia and delirium, with documented delusions. On the day of the incident, Resident 2 reported feeling threatened when Resident 1 put her fists up as if they were going to fight, and Resident 2 hit Resident 1 in the face approximately three times. Staff interviews indicated that Resident 1 had been making daily verbal death threats toward Resident 2, but the licensed nurses, DON, ADON, and Wellness and Recovery Director all confirmed they had not been notified of these threats or of the specific statement, “I’m going to kill you,” made that morning. A licensed nurse stated that if the CNA had reported the observed threat, she would have assessed the situation, determined whether the statement was related to a delusion or directed at the roommate, and attempted to redirect or separate the residents. As a result of the unreported threat and lack of timely intervention, Resident 1 sustained reddened areas and bruising on the neck and right side of the face, with bruising that persisted for 15 days.