F0610

D

Failure to Thoroughly Investigate Resident‑to‑Resident Abuse and Address Behavioral Triggers

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate two resident‑to‑resident physical abuse incidents and to identify and address contributing behavioral factors. In the first incident on 12/25/25, a resident with anxiety was seated in a wheelchair in the dining room when another resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia approached and attempted to pull the wheelchair backward. When the seated resident told him to stop, he struck her in the face without apparent provocation, causing a laceration to her upper inner lip and pain that she reported lasted a long time. The injured resident later stated she would feel afraid and unsafe if the aggressor were on the unit because of his violent nature, and she was told by staff that he was no longer in the facility.

Interviews and record review showed that the aggressive resident had known behavioral triggers, including becoming agitated when other residents went into his room or closet or were around the meal carts, and believing he was a licensed nurse who should control access to the food carts. The ADON and DSD stated that these triggers were known and that residents with unmanaged behaviors could have altercations and incidents of abuse. However, the IDT note dated 12/26/25 for the 12/25/25 altercation did not identify these behavioral triggers as contributing factors, and the resident’s care plan did not include these specific triggers or related interventions. The ADON acknowledged that after a prior incident on 11/14/25, when the same resident pushed another resident away from the food carts causing a fall, his behavior and triggers were still not identified and care planned, and that the investigation into the 12/25/25 incident did not result in corrective action to prevent further abuse. The ADON also confirmed there was no documentation that the injured resident was informed of how she would be protected from the aggressor.

In the second incident on 12/30/25, another resident with unspecified dementia and schizophrenia, who was documented as going into other residents’ rooms and slamming doors and being hard to redirect, wandered into the aggressive resident’s room and put on his clothing. Staff, including a CNA, reported that this confused resident frequently wandered into other residents’ rooms, that he had been in the aggressor’s room most of the day and refused redirection, and that this behavior would have triggered the aggressor’s aggression. The altercation occurred when the aggressive resident approached the confused resident in the hallway, yelled at him, and grabbed his arm, leading the confused resident to swing and strike him in the face, causing him to fall. Despite this pattern, the IDT note dated 12/31/25 for the 12/30/25 altercation did not identify the confused resident’s wandering into other residents’ rooms as a contributing factor, and his care plan did not address this wandering behavior with resident‑specific interventions. The ADON and administrator, who served as the abuse preventionist, acknowledged that the investigations into both incidents did not identify the behavioral triggers and wandering as contributing factors and did not include corrective actions, and that the investigative summaries did not clearly verify the incidents or specify what corrective action was taken, contrary to the facility’s policy requiring thorough investigations and follow‑up reports with sufficient information and corrective actions when allegations are verified.

The facility’s own policy on Abuse, Neglect, Exploitation or Misappropriation‑Reporting and Investigating, revised September 2022, required that all allegations be thoroughly investigated and that follow‑up investigation reports provide sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. The policy also required that the follow‑up report provide as much information as possible and that the resident and/or representative be notified of the outcome immediately upon conclusion of the investigation. In these two incidents, the administrator and ADON acknowledged that the investigations were not thorough enough, did not identify key contributing behaviors such as the aggressor’s triggers and the other resident’s wandering, did not include corrective actions, and did not document communication to the abused resident about how she would be kept safe, leading to the cited deficiency for failure to thoroughly investigate alleged abuse and respond appropriately.