F0600

G

Failure to Prevent Resident‑to‑Resident Physical Abuse on Dementia Unit

Alamosa, Colorado Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents on a dementia (Cottage) unit, despite known histories of wandering and aggression. Facility policy required prevention of all types of abuse, identification and monitoring of residents whose behaviors might lead to conflict, and having trained and qualified staff in sufficient numbers to meet residents’ needs. Several residents had documented patterns of wandering into others’ rooms, physical and verbal aggression, and disruptive behaviors, yet altercations occurred in which residents physically harmed one another. Staff interviews indicated that residents on the Cottage unit required close and continuous supervision and that there were times when no designated staff were available to monitor resident behavior when others were occupied or on break.

In one incident, a resident with Alzheimer’s disease, dementia, severe cognitive impairment, daily wandering, and a history of physical and verbal aggression entered into a physical altercation with another resident with dementia and behavioral disturbances. The aggressor pushed the other resident, who lost balance, fell, and struck his head on a chair, resulting in a 4 cm head laceration that required staples in the ED. Records showed that both residents had pre‑existing care plans addressing dementia, wandering, and physical aggression, with interventions such as redirection, removal from situations, and protection of others’ safety. However, on the night shift when the altercation occurred, these measures did not prevent the resident from becoming agitated, exit seeking, entering others’ rooms, and ultimately being involved in a physical altercation that caused injury.

Another incident involved two residents with dementia and behavioral issues, where one resident, known to wander, sleep in other residents’ beds, and have a history of physical aggression, was involved in a confrontation with another resident. During a verbal altercation, one resident grabbed the other by the shoulders and pulled her backwards, and the other responded defensively by striking the aggressor’s abdomen with the back of her hand. Both residents were assessed and found to have no injuries. Care plans for these residents documented wandering, physical aggression, and the need for monitoring, redirection, and prevention of escalation, but the altercation still occurred while staff were attempting to redirect them.

In a separate event, a resident with dementia and wandering behaviors was found lying in another resident’s bed after staff had recently assisted her to her own bed. The resident whose bed was occupied screamed, and when staff responded, both residents were found to have new scratches (one on the face, one on the forearm) consistent with a physical altercation. The resident who wandered had documented behavior problems of wandering and sleeping in other residents’ beds and a history of physical aggression, with care plan interventions including monitoring for wandering, preventing escalation of aggression, and ensuring she entered the correct room. Despite these identified needs and interventions, she was able to enter another resident’s room and bed, leading to mutual scratching injuries.

In another substantiated incident, a resident with Alzheimer’s disease, dementia with behavioral disturbance, poor impulse control, and known triggers related to searching for his wife attempted to enter a female resident’s room in the evening. A CNA observed him swinging his front‑wheel walker toward the resident and striking her in the face with his hand or closed fist, leaving a red mark and pain rated 4/10. The aggressor had a care plan for physical aggression that identified his triggers and required staff to identify behaviors early, document them, and intervene before agitation escalated. Nursing documentation also noted that he had evening and nighttime confusion, aggression, violent behaviors toward staff and other residents, and required constant supervision to redirect him from female residents’ rooms. Nonetheless, he was able to approach and strike another resident.

Staff interviews further described that all residents on the Cottage unit required close or continuous monitoring and that some residents needed redirection away from each other to avoid altercations. CNAs reported concerns about resident safety when staff were on breaks or occupied in resident rooms, leaving no designated staff to monitor behaviors. The social services director acknowledged that residents’ behaviors could increase at night and that existing interventions did not include alternatives for night redirection when activities staff were unavailable and when fewer staff were assigned after 10:00 p.m. Across these events, residents with known histories of wandering and aggression, and with care plans specifying monitoring and redirection to protect others, were not adequately protected from or prevented from engaging in physical altercations, resulting in substantiated incidents of resident‑to‑resident physical abuse.