F0600

D

Failure to Timely Intervene in Resident-to-Resident Altercation

Hayward, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure immediate interventions during a resident-to-resident altercation, allowing a verbal dispute to escalate into a physical altercation without timely staff separation. Resident 1, admitted in November 2023 with acute respiratory syndrome and an anxiety disorder, had a Brief Interview for Mental Status (BIMS) score of 15 on 9/30/25, indicating intact cognition. Resident 1’s care plan dated 11/12/24 documented a history of aggressive behavior toward other residents, with interventions that included emphasizing the resident’s responsibility for physical aggression, describing possible outcomes to self and others, and neutralizing situations by separating involved parties. Resident 2, admitted in June 2025 with late-onset cerebellar ataxia and a BIMS score of 12 on 9/26/25 indicating moderate cognitive impairment, shared a bathroom with Resident 1’s room.

According to Resident 2’s interview, the incident occurred early one morning in November 2025 when Resident 2 used the shared bathroom and heard loud yelling from the adjacent room. Resident 2 entered Resident 1’s room through the shared bathroom and observed a staff member present, then told the staff to address the yelling. Resident 2 reported that Resident 1 began yelling and ordered Resident 2 to leave the room, leading to a verbal argument in which they were “challenging each other.” Resident 2 stated that the argument escalated into a physical altercation when Resident 1 struck Resident 2 on the head with a cane, and that staff did not intervene until after the physical contact occurred, at which point male nursing staff separated them.

CNA 1, who was providing care to Resident 1’s roommate at the time, stated it was her first time working at the facility and she did not know Resident 2 was assigned to another room. She reported that Resident 2 entered through the shared bathroom and requested that she make the roommate stop yelling. CNA 1 said Resident 1 became upset, began arguing with Resident 2, and told Resident 2 to get out of the room. CNA 1 stated she also instructed Resident 2 to leave, but both residents continued to yell. She observed Resident 1 get up from the bed and both residents began shoving each other. CNA 1 did not physically intervene because she did not want to get in the middle of them and instead attempted verbal de-escalation while “keeping an eye on them” as they continued to argue. She reported that she saw Resident 1 grab a cane and hit Resident 2 on the head, and only then called for assistance, after which male nursing staff separated the residents. The DON stated staff, including registry staff, were expected to immediately separate residents as soon as a verbal altercation occurs or call for assistance if unable to safely manage the situation. Facility policies on abuse prevention and resident-to-resident altercations required protecting residents from abuse and separating residents involved in altercations and instituting measures to calm the situation.