F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Facial Injury

Pleasant Hill, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident from physical abuse when another resident struck him in the face. One resident with dementia, who was rarely/never understood, had memory problems, and never/rarely made decisions regarding daily tasks, was able to self-propel his wheelchair independently and was known by staff to be confused and to enter other residents' rooms. On the day of the incident, this resident wheeled himself along the hallway and into another resident's room without apparent staff intervention or monitoring to prevent unsafe interactions. A restorative nurse assistant, who was with another resident at the time, heard yelling, rushed to the room, and observed the second resident swinging his arm and hitting the first resident on the left side of his face while both were in their wheelchairs.

The second resident had diagnoses including anxiety and aphasia and a BIMS score of 0/15, indicating severe impairment in memory and thinking. Progress notes documented that this resident physically struck the other resident in the left eye and was angry and refused to speak with staff about the incident. Progress notes for the injured resident documented mild pain to the left eye and surrounding area, with redness and mild swelling. A nurse later stated that the incident could have been avoided by ensuring the injured resident was kept in line of sight, and emphasized that residents with severe cognitive impairment are a vulnerable population requiring protection from abuse. The facility’s abuse prohibition policy defined physical abuse as including hitting, but the incident occurred despite this policy, resulting in the resident sustaining pain, swelling, and redness near the left eye after being hit by another resident.