F0600

G

Failure to Prevent and Document Resident-to-Resident Physical Abuse

Safford, Arizona Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident and to properly assess and document the incidents in the clinical records. One victim, Resident #10, had hemiplegia, a history of CVA, dementia, and moderate cognitive impairment (BIMS 10), and was care-planned for behavior problems related to impaired cognition and safety awareness. Another victim, Resident #20, had diagnoses including cerebral ischemia, COPD, quadriplegia, TIA, and depression, with an intact cognition (BIMS 15) and a care plan noting that this resident had previously been the recipient of physical and verbal behaviors from another resident, with interventions to provide for safety and prevent such interactions. Despite these care plans, there were no progress notes in either Resident #10’s or Resident #20’s clinical records documenting any incident involving Resident #50.

Resident #50, identified as the perpetrator, had vascular dementia and other medical conditions, with a BIMS score of 15 and a care plan for behavior problems including impaired safety awareness, physical and verbal behaviors, and resistance to care. Prior documentation for Resident #50 included a note that this resident had attempted to hit staff during a separate elopement incident and required 24-hour supervision for safety. On the day of the incident, multiple witnesses, including residents, staff, and the Ombudsman, described escalating behavior by Resident #50 after becoming upset about family leaving the facility. Staff reported that Resident #50 was yelling, pushing a wheelchair with blankets, and verbally agitated. Staff #45 and a nurse initially redirected Resident #50 back to her room, but shortly thereafter, commotion was heard in the hallway where Resident #50 was observed yelling at Resident #20.

According to interviews, Resident #50 began physically striking Resident #20 while staff attempted to intervene. Resident #20, who is disabled and unable to walk, reported that Resident #50 grabbed and hit her, hurt her arm, mocked her, and made her feel afraid and abused. Resident #10, who was nearby, reported seeing Resident #50 return down the hall and hit Resident #20 in the head, prompting Resident #10 to yell for help. Staff #25 (a CNA) placed herself between the residents and reported being hit while acting as a barrier. After staff began escorting Resident #50 away, Resident #50 then approached Resident #10, who was sitting in her doorway, and struck her in the arm and head. Resident #10 later showed reddish/grey marks on her right forearm, which she attributed to the incident, and a skin assessment documented a small scratch/abrasion on that arm without any cause noted. Staff interviews, including with the DON and social services director, confirmed that Resident #50 physically struck both residents and that no documentation of the incident, its details, or the resulting injuries was entered into the victims’ clinical records, despite the DON acknowledging that this conduct met the facility’s definition of abuse and that policy requiring documentation was not followed.

The Ombudsman, who was in the building at the time, reported hearing screaming and being told by staff that Resident #50 had struck two residents, and was aware that police came to the facility. Staff #45 confirmed that she saw Resident #50 yelling at and then swinging on Resident #20, and later saw Resident #50 swing at Resident #10 while the DON attempted to block the contact. The CNA corroborated that Resident #50 and Resident #20 had a history of not getting along, that arguments tended to escalate, and that during this incident Resident #50 physically struck both residents. Resident #20 became visibly distraught and tearful when recounting the event to the surveyor and stated ongoing fear of Resident #50. Despite these events and the facility’s written policy stating residents have the right to be free from abuse, neglect, and related mistreatment, the clinical records for Residents #10 and #20 contained no incident documentation, and the single skin assessment for Resident #10 lacked any explanation of the cause of the injury, demonstrating a failure to protect residents from abuse and to document the abusive incidents in accordance with facility policy.

A review of the facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program” effective January 1, 2024, stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. The DON acknowledged that the events involving Resident #50 and the two residents constituted abuse under this policy and that the policy was not followed with respect to documentation in the clinical records. The lack of contemporaneous clinical documentation of the incidents, injuries, and assessments for the victims, despite multiple staff and resident witnesses and involvement of law enforcement, was a central factor leading to the cited deficiency.

In summary, the facility failed to prevent resident-to-resident physical abuse by a known behaviorally challenging resident and failed to document the incidents and resulting injuries in the victims’ clinical records, contrary to the facility’s own abuse prevention policy and standard documentation practices. This failure was established through clinical record review, interviews with the victims, staff, the Ombudsman, and observation of physical findings on Resident #10’s arm, as well as the absence of any incident-related entries in the clinical records of Residents #10 and #20.