F0600

D

Failure to Protect Resident From Staff Abuse and to Report Alleged Incident

Scottsdale, Arizona Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and to follow required abuse identification and reporting processes after a staff–resident altercation. Resident #6 had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, with a care plan indicating risk for unmet emotional, intellectual, physical, and social needs related to schizophrenia and directing staff to converse with the resident while providing care. A quarterly MDS showed moderately impaired cognition with a BIMS score of 10. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff, but the clinical record contained no evidence of a skin assessment after the altercation between staff and the resident.

According to the facility’s suspected abuse investigation report and staff interviews, Resident #6, in an electric wheelchair, was in the common/day room and became upset with an LPN while the LPN was at the medication cart. The resident ran into or knocked over the medication cart, spilling its contents, and used the electric wheelchair in a manner described as a weapon, moving around the day room and heading toward other residents. A CNA intervened by getting in front of the wheelchair; the resident then kicked the CNA, and the CNA responded by physically grabbing the resident’s leg, transferring the resident from the electric wheelchair to a recliner, and yelling loudly at the resident. The resident then moved himself to the floor and attempted to crawl back toward the wheelchair. The facility’s documentation and interviews confirm that the CNA’s loud, angry verbal response occurred during this altercation.

The DON and administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process for staff-to-resident abuse includes separating the parties, performing a head-to-toe assessment of the resident, and reporting suspected abuse to the State Agency within two hours, followed by an investigation. However, the progress notes from August 6, 2025, to February 3, 2026, did not document risk related to this incident, and there was no documentation of a head-to-toe or skin assessment of Resident #6 after the altercation. The DON and administrator each stated they did not consider the incident to be abuse because they believed the CNA’s actions were not intentional and were aimed at protecting other residents, and therefore the incident was not reported to the State Agency, contrary to the facility’s abuse identification and investigation policy and resident rights policy that require protection from abuse and appropriate assessment and documentation when staff are implicated in potential abuse situations.