F0600

G

Failure to Maintain Separation After Initial Altercation Leads to Resident-to-Resident Physical Abuse

Kansas City, Missouri Survey Completed on 01-08-2026

Penalty

Fine: $22,315

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse during two altercations between two residents on the same evening. One resident with schizophrenia, delusional disorder, and a history of physical aggression per PASRR approached another resident with schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, repeatedly asking for money. Both residents had care plans that identified behavioral and crisis-intervention needs, including poor impulse control and a history of violence, impulsivity, and lack of judgment, as well as instructions for staff to monitor for agitation, avoid arguing, divert attention, remove residents from situations, and intervene to protect the rights and safety of others. Despite these identified risks and interventions, the residents engaged in a verbal confrontation in the front hall outside one resident’s room, which escalated into physical violence when one resident punched the other in the head twice.

Staff intervened and separated the residents after the first incident. One resident went into his/her room with the door shut, and the other resident walked toward his/her room on a different hall. However, no staff were assigned to escort or supervise the resident returning to the back hall, and staff did not ensure that the two residents remained separated. Shortly thereafter, the resident who had returned to his/her room came back out, went looking for the other resident, and encountered him/her again near the nurse’s station. At this point, the second altercation occurred. Witness accounts and progress notes state that the aggressive resident punched the other resident in the face twice, causing him/her to fall face down to the floor, and then kicked the resident in the head twice.

As a result of the second altercation, the injured resident experienced a bloody nose, loss of consciousness, confusion upon regaining consciousness, and a bruise under the left eye. Staff and the ADON observed the resident on the floor, face down, making a gurgling sound and not responding right away. The resident was later evaluated at the hospital, where documentation noted assault, lip abrasion, contusion to the lip, and nasal contusion. Interviews with the ADON, DON, NP, and Assistant Administrator confirmed that staff did not maintain separation of the two residents after the first incident and did not escort the aggressive resident back to his/her hall, despite expectations and care plan directives to intervene and protect the safety of others. This failure to adequately supervise and separate the residents after the initial altercation led to the second, more serious physical assault and constituted a failure to protect the resident from abuse.

The facility’s own abuse and neglect policy defined abuse as the willful infliction of injury and specifically included physical abuse such as hitting, punching, and kicking. The events described, including multiple punches to the face and kicks to the head, fit the facility’s definition of physical abuse. The residents’ statements, staff interviews, and medical records consistently describe the sequence of events: repeated requests for money, escalating verbal conflict, an initial physical assault, incomplete separation and supervision, and a subsequent, more severe assault near the nurse’s station. The combination of known behavioral histories, documented care plan interventions, and the lack of continuous supervision or enforced separation after the first incident directly contributed to the occurrence of the second assault and the resulting injuries, demonstrating the facility’s failure to protect the resident from physical abuse.