F0600

D

Failure to Prevent Resident‑to‑Resident Physical Abuse Involving Cognitively Impaired Residents

Muncie, Indiana Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident who wandered from resident‑to‑resident physical abuse by another resident known to be aggressive. Resident C had documented diagnoses of moderate vascular dementia with agitation, severe dementia with agitation, anxiety, and mood disorder, and was care planned as having the potential to be aggressive, with behaviors including arguing with other residents, verbal aggression, yelling, name calling, and physical aggression when he believed others were somewhere they should not be. His care plan identified that he could become agitated and aggressive if he thought other residents were near or entering his room, and interventions included one‑on‑one supervision while awake and 15‑minute checks while asleep, as well as early intervention and removal from distressing situations. Progress notes shortly before the incident documented that Resident C was very paranoid and aggressive during a psychiatric visit and that he remained preoccupied and worried about a particular male resident going into his room.

Resident B, the victim of the abuse, had severe vascular dementia with agitation, major depressive disorder, difficulty walking, and lower back pain, and was assessed as severely cognitively impaired with wandering behavior and a need for supervision while walking. His care plans documented wandering and elopement risk, including wandering into other residents’ rooms, and multiple behavior problems such as physical and verbal aggression, putting himself on the floor, wandering around the unit, cursing staff, and throwing items. He was on 15‑minute checks and had a history of wandering into other residents’ rooms, including an incident where he wandered into another resident’s room to urinate. On the day of the altercation, earlier in the morning, Resident B and Resident C had a “cursing match” when Resident B was close to the room of another male resident, and Resident C became agitated, believing another resident was in his room. Staff redirected both residents, and no physical contact occurred at that time.

Later that same day, after mealtime, Resident B and Resident C were in or near the dining room while staff were assisting other residents to their rooms. Staff then heard yelling or a commotion from the dining area or hallway. When staff entered the hallway, they observed Resident B on the floor in a fetal position with his hands over his head, and Resident C standing over him, cursing, kicking, and stomping on Resident B’s back, sides, ribs, and head. Multiple staff witnesses consistently described Resident C as stomping and kicking Resident B in the head and rib area, with Resident B grabbing his ribs. Resident B sustained a hematoma to the right forehead, an abrasion to the left side of his face, red areas on his back, and reported generalized pain rated five out of ten. The beginning of the altercation was unwitnessed. The DON later stated that Resident C was abusive to Resident B by stomping and hitting him and that the facility should have prevented the resident‑to‑resident abuse. The Administrator acknowledged that the facility had knowledge of agitation between Resident B and Resident C earlier in the day prior to the physical assault.