F0600

D

Failure to Protect a Resident From Physical Abuse and to Implement Post‑Incident Safety Measures

Denver, Colorado Survey Completed on 01-06-2026

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 implement and document measures to ensure safety during and after the incident. Facility policy stated that the administrator was responsible for determining needed protective actions and that investigations must include observation of the alleged victim’s interactions with staff and other residents, with complete documentation of the investigation and corrective actions if allegations were verified. On the date of the incident, video footage showed one resident walking in the secured unit carrying a commercial-grade plastic coffee mug, approaching another resident seated near a door, and entering that resident’s personal space. The seated resident extended his foot and tripped the walking resident, who did not fall but immediately struck the seated resident on the top of the head with the coffee mug before walking away.

The victimized resident had vascular dementia, cognitive communication deficit, anxiety disorder, and failure to thrive, and was described as alert and oriented to one to two spheres, able to make some needs known verbally, and residing on a secure unit due to a tendency to leave the facility. Following the altercation, staff observed an open scalp wound approximately 0.4 inches in length with bleeding, and the resident reported that someone had hit him with a cup. Nursing documentation described the injury as minor and noted that the resident was stable after first aid, with no pain reported at one point and later tenderness on palpation. However, review of the electronic medical record revealed no new interventions put in place to protect this resident from the assailant after the incident and no documentation that the resident was monitored for any change from his baseline condition following the event.

The resident who struck the other had dementia with behavior disturbance, bipolar disorder, cognitive communication deficit, and an unspecified mood disorder, with documented cognitive impairment and a history of hostile and physically aggressive behavior prior to admission. His care plan identified multiple behavioral symptoms, including verbal aggression, paranoia, irritability, agitation, and a history of psychiatric hospitalizations and homelessness, and included various psychosocial and environmental interventions for agitation or aggression. After the incident, he stated that everything happened fast, that he could not remember what occurred, and that he thought someone was going to attack him. Despite his known behavioral history and the altercation captured on video, record review showed there were no new interventions added to prevent another altercation with the victimized resident. The facility’s own investigation documentation lacked evidence of immediate staff education on safety measures for the involved residents and others while the investigation was ongoing, did not identify a root cause for the incident, and did not document interdisciplinary discussion or monitoring that facility leadership later stated had occurred.