F0600

D

Failure to Prevent Resident-to-Resident Abuse by Aggressive, Wandering Resident

Groton, Connecticut Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective interventions for a resident with known wandering and aggressive behaviors. One resident had diagnoses including Alzheimer’s disease, anxiety disorder, and cognitive communication deficit, with an MDS showing severely impaired cognition, delusions, physical and verbal behaviors directed toward others, and rejection of care. The care plan identified this resident as resistive to care, physically and verbally aggressive, yelling, hitting, and pacing, with instructions to postpone care if combative and to monitor for anxiety, aggression, and delusions. Physician orders directed staff to monitor targeted behaviors of delusions and physical and verbal aggression toward staff and residents.

Despite these known behaviors, the resident entered another resident’s bathroom and, after being told to leave, slapped that resident on the left cheek with an open hand. This first resident-vs-resident incident occurred in the context of documented wandering, agitation, and aggression, including notes that the aggressive resident hit staff, threw a cup of juice at staff, was verbally aggressive, refused to use a walker, refused to stop wandering into other residents’ rooms, and was not easily redirected. The care plan developed after the first incident identified that the resident used to work in a prison and was triggered when told “no,” and included interventions such as diversion, removal from the environment, and observation for non-verbal signs of physical aggression. However, the care plan did not address the possibility of this resident wandering into other residents’ rooms.

Subsequently, another resident with Alzheimer’s disease, anxiety disorder, bilateral hearing loss, and moderate cognitive impairment, who had a care plan noting potential physical behaviors, lack of personal space boundaries, and yelling, was assaulted when the aggressive resident again entered a resident room. In this second incident, the aggressive resident entered the room, yelled at the other resident, demanded compliance, then slapped the resident on the left side of the face and grabbed the right upper arm. The psychiatric evaluation documented that the aggressive resident had a previous resident-to-resident incident and recent episodes of physical aggression without evidence of infection. The facility’s failure to incorporate the known wandering and room-entry behavior into the care plan and to implement effective interventions to prevent further resident-to-resident contact contributed to this second incident of abuse.