F0600

D

Failure to Protect Residents From Physical and Verbal Abuse by Other Residents

Boulder, Colorado Survey Completed on 10-02-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from abuse, including physical and verbal abuse, primarily involving one resident with known behavioral issues. Facility policy defined abuse broadly, including resident-to-resident altercations, and required written procedures to prohibit and prevent abuse, neglect, and exploitation, as well as investigation and staff training. Despite this, the facility did not consistently act on known patterns of threatening and aggressive behavior by one resident toward male residents, nor did it investigate all threatening notes or verbal threats as potential abuse incidents.

One incident involved a cognitively intact male resident with schizoaffective disorder, diabetes, major depressive disorder, PTSD, and a history of being the victim in altercations. He reported that another resident with schizophrenia, cognitive impairment, delusions, hallucinations, and a history of odd and sexually threatening statements had threatened him multiple times, including threats to kill him and cut him into small pieces in his bathroom. He stated that this resident had physically hit him by striking his cheek and pulling his beard when they returned from the smoking patio, and that he had reported these incidents to staff. He also reported that this same resident had hit another male resident. The behavior care plan for the aggressor resident documented delusions, hallucinations, refusal of care, sexual and odd statements, yelling at other residents, and behaviors mostly directed toward males, yet the facility did not prevent the subsequent physical contact and threats that occurred.

Another male resident with dementia, psychotic and mood disturbances, depression, anxiety, and moderate cognitive impairment reported that the same aggressor resident had thrown water on his head months earlier and that he notified staff but "they did nothing." He also reported that she sometimes spoke to him in an aggressive way. A third cognitively intact male resident with cerebral atherosclerosis, sequelae of cerebral infarction, generalized anxiety disorder, anxiety, ineffective coping, and verbal aggression reported that the same aggressor resident entered his room and left a note stating she would come to his bedroom and cut his penis while he slept. He stated he should not be threatened in that way, reported it to staff, and believed nothing would be done, adding that she had threatened others verbally or with notes and went into men’s bedrooms, causing him fear. The DON, acting as abuse coordinator, acknowledged awareness that this resident passed threatening notes to residents and staff, characterized the notes as part of her behavior, stated she was not dangerous, and reported that the facility did not investigate every note she wrote.

The deficiency also includes an observed incident of verbal abuse between two cognitively intact male residents. One resident with PTSD, severe major depressive disorder, COPD, diabetes, and a cognitive communication deficit, who had a care plan noting a loud voice often perceived as yelling and risk for verbal altercations, was speaking loudly near the nurse’s station. Another resident with anxiety, ineffective coping, and verbal aggression came out of his room and yelled racial and discriminatory insults and profanity at him, and the first resident yelled back using similar language. This altercation, involving racial and discriminatory insults, was witnessed by staff, other residents, and surveyors. Staff interviews confirmed that the loud resident often spoke in a way that disturbed others and that the verbally aggressive resident had prior arguments with him, usually initiated by the verbally aggressive resident, but the facility had not effectively prevented such abusive exchanges.