F0600

D

Failure to Protect Resident From Peer Physical Abuse Resulting in Facial Injury and Fear

Sonora, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with vascular dementia, who had been receiving quetiapine 50 mg three times daily for behaviors including aggression and wandering, was seated near the nursing station on the day of the incident. Progress notes from the prior day documented that this resident became aggressive with staff when they attempted to provide standby assistance during ambulation, but did not document aggression toward other residents. On the day of the event, staff observed this resident rise from a chair by the nursing station, approach another resident who was also seated there, stand in front of the second resident, and unexpectedly strike the second resident in the face with a fist while repeatedly yelling that the other resident was “the devil.”

The resident who was struck had diagnoses including depression, dementia, and anxiety, and was severely cognitively impaired per a BIMS score of 03. Immediately after the assault, this resident appeared shocked and quiet, with a facial expression of disbelief, and reported being hit in the face while pointing to the left mouth region. Assessment revealed a cut and bleeding upper lip at the left corner of the mouth, with slight swelling, bruising, and small dots of blood noted on a washcloth. The injured resident later stated that the blow was forceful, caused pain, and resulted in visible blood from the lip injury. The facility’s own documentation characterized this event as the resident becoming a victim of unprovoked and unexpected physical abuse from a peer resident.

Interviews with staff and leadership confirmed that the facility recognized the event as abuse under its Abuse and Neglect Prevention and Investigation policy, which defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, including abuse by other residents. The DON acknowledged that the altercation between the two residents met the policy definition of physical abuse and that an injury occurred as a result of the aggressive act. Staff reported that the aggressive resident had been suspicious and paranoid that day but had not previously been physically aggressive toward other residents, and they expressed surprise at the assault. The injured resident later reported ongoing fear and nervousness that the aggressive resident might hit her again, and the DON stated she had not been aware of this continuing emotional distress. The facility’s monitoring documentation showed multiple episodes of aggressive behavior for the aggressive resident around the time of the incident, but it did not specify whether the aggression was directed toward staff or other residents or describe the type of aggression, contributing to the deficiency in protecting residents from abuse.

The facility’s policy on Abuse and Neglect Prevention and Investigation, dated 5/7/25, states that residents have the right to be free from verbal, sexual, physical, and mental abuse, and that abuse or neglect of residents by anyone, including other residents, is not condoned. Despite this policy, the aggressive resident was able to physically assault the other resident at the nursing station, resulting in a bleeding lip, swelling, bruising, and pain, as well as fear and anxiety for the victim. The DON confirmed that, by the facility’s own policy definition, the incident constituted physical abuse of one resident by another, demonstrating that the facility failed to ensure the victim’s right to be free from physical abuse was protected.