F0600

D

Failure to Prevent Resident-to-Resident Abuse Resulting in Bruising

Carlyle, Illinois Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse during a resident-to-resident altercation. One resident (R1), who was cognitively intact and used a walker and wheelchair, had diagnoses including cerebral infarction, hypertensive heart disease with heart failure, asthma, chronic pain, major depressive disorder, gastric ulcer with hemorrhage, and was on anticoagulant therapy with a care plan noting increased risk of bruising and bleeding. Another cognitively intact resident (R2), who used a wheelchair, had diagnoses including cerebral infarction, major depressive disorder, type 2 diabetes with chronic kidney disease, chronic pain, anxiety disorder, and had a care plan focus area for aggressive behavior, including cussing and yelling profanities, with interventions to manage such behavior.

On the day of the incident, R1 reported that R2 had been eating his snacks without permission. According to R1’s progress note, when R1 confronted R2, R2 got out of his wheelchair and attempted to hit him. R1 stated he grabbed R2 by the shirt because R2 was attempting to hit him, and R2 then fell to the floor and began kicking R1 in the lower legs. When nursing staff entered the room, they observed the two residents verbally arguing, with R2 balling up his fists and yelling profanities. R2’s progress note documented that he was found sitting on his bottom with his back against the wall and that he stated he had stood up and lost his balance, causing him to fall, while also balling up his fist in a threatening manner and yelling profanities at R1 and staff.

Subsequent documentation and interviews confirmed that R1 sustained a large blue/purple bruise around the left lower extremity calf area that was very tender, and that R1 reported being kicked by R2. A CNA (V3) stated the incident was unwitnessed, that R2’s shirt was torn, and that R1 later had a bruise on his leg, noting R1 was on blood thinners and bruised easily. The administrator (V1) stated the altercation occurred less than 24 hours after R2 was moved into R1’s room and that both residents had prior stroke-related weakness, with R1 also having visual impairment and being on a blood thinner and anemic. The facility had a policy on resident-to-resident altercations requiring investigation and identification of what led to aggressive conduct, and the survey finding concluded the facility failed to ensure residents remained free from abuse for one resident reviewed for abuse.