F0600

G

Failure to Identify and Care Plan Behavioral Triggers and Wandering Led to Resident‑to‑Resident Abuse

El Cajon, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse by not identifying, assessing, and care planning for known behavioral triggers and wandering behaviors. One resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia had documented triggers related to perceived theft, other residents entering his room or closet, and residents being near or touching the meal carts. Despite this, his behavioral triggers were not identified in his care plan, and staff assigned to him, including CNAs and licensed nurses, reported they were unaware of his specific triggers or PTSD diagnosis. The resident was also allowed to wear tape on his jacket labeling himself as an LVN, which staff stated could empower him and cause other confused residents to approach him as if he were staff, potentially provoking aggressive responses.

This failure to manage the resident’s behaviors led to multiple resident‑to‑resident altercations. On one occasion, another resident was standing near the food cart when the aggressive resident pushed him aside, causing the resident to lose his balance and fall to the ground. On another date, a cognitively intact resident seated in a wheelchair in the dining room was approached by the aggressive resident, who attempted to pull her wheelchair backwards. When she told him to stop, he punched her in the mouth with a closed fist, causing a laceration to her upper inner lip, pain, and distress; she later reported that a tooth was loosened and that staff were not close enough to intervene before she was struck. Staff witnesses and leadership consistently characterized these acts of pushing and punching as physical abuse.

The same aggressive resident also confronted a highly confused, cognitively impaired resident with dementia and schizophrenia who wandered and entered other residents’ rooms. Staff documented and reported that this wandering resident frequently went into others’ rooms, slammed doors, and was hard to redirect despite calm approaches and explanations. On the day of another altercation, staff observed that the wandering resident had been in the aggressive resident’s room most of the day and was not redirectable, and later put on the aggressive resident’s clothing. When the aggressive resident encountered him, he yelled at and grabbed the wandering resident’s arm; before staff could intervene, the wandering resident struck him in the face, causing him to fall to the floor and be sent to the hospital for evaluation. The facility’s own policies required identification of behaviors that could provoke reactions, assessment of triggers, and care plan changes after altercations, but interviews and record review showed that neither the aggressive resident’s triggers nor the wandering resident’s room‑entering behavior were identified, assessed, or incorporated into their care plans, contributing to repeated incidents of resident‑to‑resident abuse on the secured unit.

In addition, the facility did not fully address the impact of the abuse on affected residents. The cognitively intact resident who was punched in the mouth reported significant pain lasting a long time and fear of the aggressive resident, stating she would not feel safe if he remained on the unit and that she knew he had hit other residents before. She was told by staff that the aggressive resident was no longer in the facility and was gone, rather than being informed of a specific plan to keep her safe from him. There was also no documentation that she was evaluated by a physician or dentist after being punched in the mouth, despite her oral injury and pain. Another roommate of the aggressive resident reported being afraid of him and stated that the aggressive resident had threatened to kill him, which staff considered believable given their knowledge of his prior aggressive acts.

The facility’s own leadership and clinical staff acknowledged that unmanaged behaviors, such as the aggressive resident’s responses to perceived theft and control of food carts, and the other resident’s wandering into rooms and rummaging, could lead to altercations and abuse. They further acknowledged that these behaviors and triggers were not identified, assessed, or incorporated into individualized care plans, and that staff on the secured unit were not consistently aware of which residents had been involved in altercations with the aggressive resident. As a result, residents on the secured unit, including those with cognitive impairment and mental disorders, were exposed to repeated episodes of physical abuse and altercations stemming from unaddressed behavioral triggers and unsafe wandering into other residents’ rooms.