F0600

D

Failure to Supervise Leading to Resident-to-Resident Physical Abuse

Avon Park, Florida Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident abuse, resulting in a physical altercation between two residents. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including abnormalities of gait and mobility, muscle weakness, and type 2 diabetes, alleged that another resident kicked her, causing a fall and subsequent left shoulder pain. Resident #3, who had severe cognitive impairment with a BIMS score of 6 and diagnoses including unspecified mood disorder, depression, and dementia, had a documented history of verbally and physically threatening staff and other residents, aggressive behavior, and pilfering items. The facility’s care plan for Resident #3 identified behavioral symptoms and cognitive loss/dementia, with approaches including redirection, diversional activities, and, later, 1:1 sitter supervision.

Prior to the incident, staff were aware that Resident #3 exhibited verbal aggression and had prior altercations with other residents to the point of needing separation, and that the two involved residents had previously been roommates who did not get along, leading to a room change. Resident #3 was also on Depakote for mood instability, mood swings, and aggression, with behavior monitoring ordered. However, the behavior monitoring documentation for January showed only intervention codes (e.g., giving food, fluids, encouraging rest) without any description of the specific behaviors exhibited, and facility staff, including the MDS coordinators, could not state what behaviors had occurred on those dates despite acknowledging that some type of behavior must have been present. The facility’s abuse policy required identification of residents with behaviors that might lead to conflict, sufficient supervision, and monitoring for changes that could trigger abusive behavior, but the documentation and staff interviews did not demonstrate clear, behavior-specific monitoring or consistent preventive supervision.

On the day of the event, the altercation occurred in the east wing atrium/common area near the nurses’ station. Resident #8, another resident, reported witnessing Resident #3 approach Resident #2 in a wheelchair, exchange derogatory names, stand up from their wheelchairs, and then kick Resident #2 in the shin, causing Resident #2 to fall to her left side. Resident #8 stated no staff were present at the time. Staff B, an RN, reported hearing Resident #2 crying and asking for help, then seeing her in her wheelchair and separating the residents, but did not witness the actual kick or fall. The DON’s investigation notes, based on interviews, indicated that Resident #3 admitted to pushing another resident after a verbal altercation, and that Resident #2 and Resident #8 both described Resident #3 kicking Resident #2 and causing her to fall. The facility’s abuse policy required sufficient staffing, supervision, and obtaining signed witness statements, but the DON confirmed that written, signed staff statements were not obtained from key staff present that shift, and staff could not clearly account for supervision at the time of the incident, supporting the finding that the facility failed to provide adequate supervision to prevent resident-to-resident abuse.