F0600

K

Failure to Prevent and Care Plan Resident-to-Resident Physical Abuse

Front Royal, Virginia Survey Completed on 01-12-2026

Penalty

Fine: $34,230

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, primarily on the memory care unit, over an extended period. Resident-on-resident altercations repeatedly occurred in which one resident struck, hit, pulled hair, or otherwise physically contacted another resident, often involving the same aggressor. For example, one resident repeatedly struck other residents in the face, head, shoulder, arm, and mouth, and pulled another resident’s hair while they were seated in the dining room. In many of these events, staff documented that the aggressor resident became agitated or combative, particularly when other residents were in her personal space, when she perceived staff as needing protection, or immediately after receiving care.

The clinical records and final event synopses show that affected residents were typically seated in common areas such as the dining room or wandering on the memory care unit when they were struck or otherwise physically abused. In several cases, staff or other residents witnessed the incidents and separated the residents, and progress notes documented assessments showing either no visible injury or minor findings such as a small red spot on the nose, bruising to the upper lip, or a fall to the floor after being hit on the shoulder. Many of the residents involved had cognitive impairment and were unable to recall the incidents when interviewed afterward, though one resident later described being “whacked” across the face. Staff interviews acknowledged that residents on the memory care unit wander, can become easily agitated, and are especially vulnerable due to cognitive status and limited ability to communicate symptoms.

Across all cited residents, the comprehensive care plans in place at the time of the incidents did not contain information related to these episodes of resident-to-resident abuse. Care plans for residents who were struck, hit, or had their hair pulled lacked any documentation of the abuse incidents or individualized approaches addressing these behaviors or the residents’ vulnerability to further altercations. This absence of care plan interventions was noted for multiple residents who experienced one or more abusive encounters, including those who were struck on more than one occasion by the same aggressor. Facility staff, including nursing and social services personnel, stated in interviews that any willful striking, hitting, smacking, or hair-pulling by one resident toward another constitutes physical abuse and that residents have the right to be free from abuse, consistent with the facility’s written abuse policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish.

In addition to the repeated incidents involving a primary aggressor on the memory care unit, other residents were abused by different residents who became combative when their personal space was invaded. In these cases, staff witnessed residents being hit on the arm or chest and a resident being struck on the shoulder, causing a loss of balance and a fall. Progress notes documented that affected residents were assessed and often had no recall of the negative encounters. Despite these documented events and staff recognition that such conduct constitutes abuse, the corresponding care plans for the abused residents did not reflect the incidents or any related information. The pattern of resident-to-resident physical abuse, combined with the lack of care plan documentation addressing these events, formed the basis of the cited deficiency and led to a determination of immediate jeopardy for residents on the memory care unit.

Removal Plan

• Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
• Provide follow up psychosocial support from social services to Residents #58, #94, #25, #13, #41, and #68.
• Screen all residents for evidence of abuse and neglect.
• Complete an abuse questionnaire for residents who are interviewable (BIMS score of 8 or greater).
• Complete a head to toe physical assessment for non-verbal residents or residents with a BIMS score of 7 or below.
• Address any identified concerns according to the HVHC Abuse and Neglect Policy.
• Conduct an audit of all incident reports for the last 30 days to ensure that all events meeting the reporting requirements were reported to the appropriate parties.
• Reeducate all staff of the facility/agency on the HVHC Abuse and Neglect Policy, including abuse prevention, types of abuse, abuse reporting, and the Elder Justice Act specifically pertaining to resident to resident altercations.
• Require any staff not present for the education to receive mandatory education prior to the start of their next shift.
• Prohibit staff from returning to work until the mandatory education has been completed.
• Include this training in new hire orientation as part of the new hire process.
• Require all agency staff to complete this education prior to starting work in the facility.
• Provide reeducation to facility leadership (NHA, DON, social services, activities) on abuse reporting and investigating allegations of abuse and resident altercations.