F0600

G

Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Wrist Fracture

Mattoon, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to protect residents from physical abuse by another resident, resulting in one resident sustaining a fractured right wrist. One resident had a care plan dated 8/14/25 indicating verbal behaviors such as yelling and threatening others, and another resident had a care plan dated 4/15/24 documenting impaired moods/behaviors with physical behaviors including hitting others, swinging a purse at others, throwing things, attempting to break windows, and flashing others. On the night of 12/27/25, while an LPN was passing medications, a CNA informed her that one resident was on the floor after being pushed by another resident. The LPN found the resident on the floor near the nurse station close to the fireplace, attempted to assess her, and the resident refused assessment and demanded to be sent to the hospital. The LPN reported that the resident who fell may have provoked the other resident, which may have led to the pushing.

The CNA later stated she was present when the incident occurred but did not see how it started; when she turned around, she saw one resident push the other, causing a fall to the ground. She reported that staff separated the residents and notified the nurse, and she wrote a statement about the incident. The resident who fell was sent to the emergency room for evaluation and returned the next day with a soft cast to the right hand. An X-ray dated 12/28/25 documented a shattered and displaced distal radius fracture. During a later observation, the injured resident was seen sitting in a common area with a platform walker and a wrist brace, and stated that her hand was broken because she interfered in a fight and was pushed, though she could not identify who pushed her. These events occurred despite prior documentation of both residents’ behavioral issues in their care plans.