F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse

Chicago, Illinois Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assert residents’ rights and prevent resident-to-resident abuse when one resident physically struck another. Resident 1 had multiple psychiatric and substance use diagnoses, including schizoaffective disorder, bipolar disorder (current manic episode), schizophrenia, anxiety disorder, depression, and psychoactive substance abuse, and had been assessed as at moderate risk for aggression with a documented need for re-evaluation of services due to recent behavior. Resident 1’s care plan noted persistent anger toward self and others related to feelings of abandonment and psychotic symptoms. On the day of the incident, progress notes documented that Resident 1 became physically aggressive toward a peer without provocation, exhibited increased agitation, and was unable to be redirected. The Administrator (who also served as abuse coordinator) reported that during a morning meeting staff heard a noise, came out, and observed Resident 1 in a behavioral episode; the Administrator personally witnessed Resident 1 slap Resident 2 across the back of the head. The Nursing Supervisor stated he was aware that Resident 1 hit Resident 2 and that he had previously observed Resident 1 upset and aggressive on other occasions.

Resident 2’s progress notes documented that Resident 2 received physical contact from a peer, that the residents were immediately separated, and that a head-to-toe assessment revealed no visible bruises or injuries, with Resident 2 denying pain or discomfort and vital signs stable. Resident 2’s care plan stated that the resident would remain safe, be treated with respect and dignity, and reside free from mistreatment, including abuse and neglect, and that a safe environment and emotional support would be provided, especially during investigations. During interview, Resident 2 did not recall the incident but confirmed that Resident 1 had been a girlfriend and was no longer in the facility. The Administrator stated she believed Resident 1 did not hit Resident 2 willfully and was just having an episode, despite the facility’s abuse policy defining abuse as the willful infliction of injury and clarifying that “willful” means the individual acted deliberately, not that they intended to inflict harm. The facility’s own Facility Reported Incident documented that Resident 1 made physical contact with Resident 2, and the abuse prevention policy identified physical abuse as including hitting and slapping, underscoring that the resident-to-resident physical contact met the facility’s definition of abuse that should have been prevented.