F0600

G

Failure to Protect Cognitively Impaired Residents From Repeated Peer‑to‑Peer Physical Abuse

Granite City, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from resident‑to‑resident abuse, resulting in multiple physical assaults by one cognitively impaired resident against other cognitively impaired residents. The resident identified as the aggressor had a documented history of dementia with behavioral disturbance, traumatic brain injury, agitation, aggression, and prior violent episodes, including physically aggressive behavior toward his wife at home, attempts to elope, and an incident in which an RN was knocked to the ground during a prior hospitalization. His MDS showed severe cognitive impairment (BIMS 0) and physical behavioral symptoms directed toward others, such as hitting or pushing, occurring 1–3 days and placing him at significant risk for physical illness or injury. His care plan noted a history of physical aggression toward staff related to dementia and identified him as at risk for abuse/neglect due to impaired cognition and need for ADL assistance.

One incident involved this resident entering another resident’s room and assaulting him with a walker. The victim in this event had Alzheimer’s disease and dementia with behavioral disturbance, was severely cognitively impaired, resistive to care at times, and dependent on staff for most ADLs. Progress notes documented that staff heard a resident screaming for help and then observed the aggressor hitting this resident with a walker. The victim was found with a head injury and was transported to the ED, where he was diagnosed with a physical assault and a 2‑cm scalp laceration that required repair with staples. This event occurred despite both residents being care planned as at risk for abuse/neglect related to dementia and impaired cognitive skills.

A second incident occurred when the same aggressive resident entered another male resident’s room after using a shared bathroom. The victim, who had severe cognitive impairment, dementia without behavioral disturbances, anxiety, and required assistance with ADLs, reported that he approached the aggressor to tell him he was in the wrong room. The aggressor then stood up and struck him across the face with an open hand. Staff heard the victim scream from the dining area and, upon his arrival at the nurse’s station, observed redness to the right side of his face around his eye. An IDPH final report confirmed that the physical altercation occurred, that a small red area was present near the right eye, and that both residents resided on the memory unit.

A third incident involved the same aggressive resident entering a female resident’s room and striking her in the face with a cane while she was asleep in bed. This victim had dementia with agitation, restlessness and agitation, anxiety disorder, paroxysmal atrial fibrillation, severe cognitive impairment, and required assistance with ADLs. Her care plan identified her as at increased risk for abuse and neglect related to dementia with behavioral disturbances. Progress notes documented that yelling was heard, and when staff arrived, they saw the aggressor standing over her holding a cane. The resident sustained a laceration to the right side of her jawline, reported pain at 8/10, and was noted to be frantic but resting quietly after the event. An IDPH final report documented that the LPN heard yelling, found the aggressor standing over the resident with a cane, and observed bleeding from the jawline laceration.

Interviews with staff and facility leadership further described the aggressor’s unpredictable and unprovoked aggressive episodes. A resident aide stated that he could become agitated quickly, did not like redirection, and staff never knew when he would become aggressive. An LPN reported hearing a scream, running to the room, and seeing the aggressor standing over the female resident with a cane raised to strike again, noting that he became aggressive when he believed someone was in his room or personal space. The social service director stated she was not aware of his aggression when he was accepted, while the DON stated that she and the SSD had visited him in the hospital, found him calm and cooperative, and were told by hospital staff that he had been cooperative except for the initial ER incident. The administrator and DON both acknowledged that the aggressor was very protective of what he believed was his bed, that he would have an issue if he saw someone on it, and that all residents were at risk because staff never knew when he would “go off.” Despite the facility’s written Abuse Prevention and Prohibition Program stating that the facility screens for potentially abusive residents during pre‑admission and maintains adequate staffing to meet residents’ needs, these resident‑to‑resident assaults occurred, demonstrating a failure to ensure residents were free from abuse by other residents.

The facility’s Abuse Prevention and Prohibition Program also stated that the facility is committed to protecting residents from abuse by anyone, including other residents, and that it conducts ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences. However, the documented history of the aggressor’s dementia with behavioral disturbance, prior aggression toward caregivers, and multiple in‑facility assaults on other residents shows that, in practice, residents were not adequately protected from resident‑to‑resident abuse. The combination of the aggressor’s known behavioral risks, the severe cognitive impairment and dependence of the victims, and the repeated episodes of physical assault within the memory unit formed the basis of the cited deficiency for failure to ensure residents were free from abuse.