F0600

D

Failure to Prevent Resident-on-Resident Physical Abuse in Common Areas

Colorado Springs, Colorado Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect two residents from physical abuse by other residents, despite existing policies intended to prohibit and prevent abuse. The facility’s Abuse, Neglect, and Exploitation policy required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and attention to environmental factors that could make abuse more likely. In practice, residents with known behavioral histories and cognitive impairments were in shared environments such as the dining room and smoking area where altercations occurred. The report documents that these incidents were substantiated as physical abuse.

In the first incident, an altercation occurred in the dining room between Resident #7, who had schizoaffective disorder, depression, severe cognitive impairment, expressive aphasia, and a history of being both an aggressor and a recipient of physical aggression, and Resident #9, who had stroke with left-sided paralysis, bipolar disorder, depression, anxiety, and a documented history of taking items from staff, swinging at staff, and throwing objects at other residents. Resident #7 had verbal behavioral symptoms toward others and a behavior of agitating other residents by pointing and muttering. Resident #9 had a history of behavioral outbursts during psychotic episodes. While residents were in the dining room waiting for dinner, a witness reported that Resident #9 hit Resident #7 several times in the chest and shoulder. Resident #7 was unable to verbally report the incident due to expressive aphasia.

Prior to this altercation, both residents had care plans identifying behavioral issues, but the interventions in place at the time did not prevent the physical abuse. Resident #7’s mood and behavior care plan, initiated earlier, identified her as both an aggressor and a recipient of physical aggression, and Resident #9’s care plan documented prior physical aggression toward staff and other residents. The interdisciplinary team later attributed the altercation to impulsivity and behavioral histories, but at the time of the event, Resident #7 and Resident #9 were together in the dining room without effective preventive measures that would have kept Resident #7 free from physical abuse.

In the second incident, a physical altercation occurred between Resident #10 and Resident #11 during a supervised smoking break. Resident #11 had a history of traumatic brain injury, Parkinson’s disease, dementia, schizophrenia, depression, and anxiety, with severe cognitive impairment and documented verbal behaviors toward others. His care plans noted verbal aggression, triggers such as others staring at him and waiting for cigarettes, and difficulty understanding others due to cognitive and communication deficits. Resident #10 had mood disorder, depression, anxiety, personality disorder, and a documented history of anxiety with verbal aggression and physical aggression toward other residents, including a care plan specifically addressing physical aggression.

During the smoking break, Resident #10 became agitated when Resident #11’s legs were in close proximity. Resident #10 stood up from his wheelchair and attempted to swing at Resident #11, who responded by placing his foot against Resident #10’s chest to create distance. Resident #10 then pulled himself closer, grabbed Resident #11 by the shirt, and punched him in the face near his right eye multiple times. A staff member was present supervising the smoking break but was unable to intervene in time to prevent the blows. Resident #11 was later found to have a small red area on the right side of his face and redness on his right cheek and jaw. Both residents had known histories of aggression and impulsivity, and the interdisciplinary team later attributed the altercation to a misunderstanding of personal space, but at the time of the event, the supervision and existing behavioral interventions did not prevent Resident #11 from being physically abused by Resident #10.