F0600

G

Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Head Trauma and Repeated Assaults

Chicago, Illinois Survey Completed on 01-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse by other residents, resulting in multiple substantiated abuse incidents. One resident with intact cognition and diagnoses including traumatic subdural hemorrhage, nasal bone fracture, schizophrenia, and bipolar disorder reported being physically assaulted in his room by another cognitively intact resident with schizophrenia and other psychiatric diagnoses. According to the injured resident, he initially went to the aggressor’s room to borrow a lighter, was told there was no lighter, and then returned to his own room. Shortly thereafter, the aggressor entered his room, demanded to know where his cigarettes were, and then punched him in the face repeatedly with a closed fist. A nurse heard a loud noise, saw the aggressor leaving the injured resident’s room, and found the injured resident lying on his bed with his face covered in blood. The injured resident was sent to the hospital and diagnosed with a subdural hematoma and a nasal bone fracture, with hospital documentation noting facial trauma including left periorbital swelling and a right nasal bone fracture.

The aggressor in this incident had a documented history of mental illness, hallucinations, and delusions, and staff and the Psychiatric Rehabilitation Services Coordinator acknowledged that he had prior behavioral incidents with other peers, including breaking shelves at the nursing station and two prior incidents with another resident, though not as severe as the assault that caused the subdural hematoma and nasal fracture. Staff interviews indicated that when residents exhibit aggressive behavior they may be placed on one‑on‑one monitoring and receive psychiatric evaluation, and that staff are expected to monitor hallways, particularly at night, to prevent residents from wandering into other residents’ rooms. At the time of the assault, the aggressor was not on one‑on‑one monitoring, and the event occurred in the early morning hours when residents do not have scheduled smoking times. The administrator, who serves as the Abuse Coordinator, stated that it is not expected for residents to be physically abused by other residents and that the facility must keep residents safe, and the physician stated that abuse is not an expectation and that behaviors should be managed to maintain safety.

Additional substantiated abuse incidents involved another resident with schizophrenia and severe cognitive impairment who physically struck two cognitively intact residents on separate occasions. In one incident, a cognitively intact resident with schizophrenia, hypertension, and unsteadiness on feet was sitting in the hallway after exiting the dining room when the cognitively impaired resident walked out of her room and, without provocation, struck him in the face with her hand. The LPN on duty heard the victim yell “stop hitting me,” saw the aggressor standing close to him making a fist, and separated them. The facility’s final incident investigation concluded that abuse was substantiated, determining that the resident was struck in the face by another resident. In another incident, a cognitively intact resident with osteoarthritis, hypertension, and psychosis was inside a public restroom when she opened the door as the same cognitively impaired resident was walking past. The aggressor was reportedly startled, began swinging her arms, and struck the resident in the face. Staff on the unit intervened immediately and separated the residents. The facility’s final incident investigation again substantiated abuse, concluding that the resident was struck in the face by another resident when the restroom door opened and the aggressor reacted by swinging her arms. Progress notes documented that the aggressor later, without event or provocation, hit another peer in the face and then became physically aggressive toward staff attempting to intervene.

Across these events, the facility’s own Residents’ Rights document states that residents must not be abused physically, neglected, or exploited by anyone and that the facility must provide services to keep residents’ physical and mental health at their highest practicable levels. The Abuse Prevention Program Policy defines abuse as physical or mental injury inflicted upon a resident, including hitting, slapping, and kicking, and affirms residents’ right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The administrator confirmed that the allegations involving the residents who were struck in the face were substantiated as physical abuse based on the nature of the incidents and resident statements, meaning that abuse occurred. Despite these policies and expectations, multiple residents were physically assaulted by other residents on different dates, including one incident that resulted in significant head trauma and facial fractures, demonstrating that the facility failed to protect residents’ rights to be free from physical abuse by other residents.