F0600

D

Failure to Protect Resident From Physical Abuse by Another Resident

Anaheim, 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, as required by its abuse prevention and reporting policy. The facility’s policy, revised in 4/2024, defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm or mental anguish and emphasized protection of resident rights and investigation/reporting of alleged violations. Despite this policy, an incident occurred in which one cognitively impaired resident (Resident 2) pushed another cognitively impaired resident (Resident 1) when Resident 1 attempted to enter Resident 2’s room.

On the date of the incident, the facility’s SOC 341 documented that Resident 1 tried to get into Resident 2’s room, and Resident 2 pushed Resident 1 in the chest, causing Resident 1 to back off, lose balance, and fall. Resident 2’s medical record and MDS showed severe cognitive impairment, and progress notes documented that Resident 2 stated she was trying to stop Resident 1 from entering her room and admitted to pushing her. A nurse (LVN 3) found Resident 1 on the floor near a room, crying and complaining of hip pain, with Resident 2 standing by the door and stating she had given Resident 1 “a little shove” to stop her from going into the room. Another nurse (LVN 1) confirmed that Resident 2 admitted to pushing Resident 1.

Resident 1’s medical record showed that she lacked capacity to understand and make decisions and, prior to the incident, required only set-up or clean-up assistance for bed mobility and transfers and could walk 150 feet with supervision or touching assistance without an assistive device. Following the fall, Resident 1 complained of left hip pain, and radiology on the date of the incident showed fractures of the left superior and inferior pubic rami, with a subsequent CT scan at the acute care hospital confirming recent fractures of the left lateral superior pubic ramus and left inferior pubic ramus. After the incident, therapy documentation reflected a decline in functional status, with Resident 1 requiring partial to maximal assistance for bed mobility, transfers, and ambulation with a two-wheeled walker, and nursing and CNA interviews described increased pain, frequent screaming and yelling due to pain, and dependence on staff for activities of daily living. These findings support that the facility failed to protect Resident 1 from physical abuse by another resident in accordance with its abuse prevention policy.