F0600

G

Failure to Prevent Resident-on-Resident Physical Abuse and Inadequate Supervision of a Dementia Resident

Chicago, Illinois Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent and protect a cognitively intact resident (R1) from physical abuse by another resident (R2) who had dementia and a documented potential for aggressive behavior. R1 reported that while she was lying in bed in the evening, an unknown male, later identified as R2, entered her room, came directly to her side of the bed, and attempted to pull her sheets down. R1 stated that R2 then moved toward the front of her bed, tried to move her bedside table, and when she resisted by holding onto the table, he punched her in the face. R1 described crying, calling for help, and contacting her family member (V3) immediately after the incident. The surveyor observed a red bruise under R1’s left eye, and R1 reported facial swelling earlier, pain treated with medication and an ice pack, and significant emotional distress, including uncertainty about feeling safe in the facility.

R1’s family member (V3) corroborated R1’s account, stating that R1 called him crying and saying she had been hit, and that she described an unknown male entering her room, attempting to pull down her blanket, trying to move the bedside table, and then punching her in the face when he could not move it. V3 reported that R1 was screaming for help and that he had to call the front desk to alert staff that R1 was being attacked. When V3 arrived at the facility, he initially could not locate staff at the nurse’s station and subsequently filed a police report. V3 stated that R2 could have seriously harmed R1 and emphasized that staff were responsible for ensuring R1’s safety and monitoring R2 and other residents.

R2’s records documented diagnoses including unspecified dementia, suicidal ideations, and major depressive disorder, with an MDS indicating memory problems and inability to complete the BIMS. R2’s care plan identified a potential for aggressive behavior related to dementia and directed staff to observe his location and changes in aggression level and to remove him from areas when aggression increased. Staff interviews revealed that R2’s room was directly next to R1’s and both rooms were across from the nurse’s station. A CNA (V5) stated she had checked R2 about ten minutes before the incident and found him asleep, and that she later heard a call for help, entered R1’s room, and saw R2 standing by R1’s bed while R1 held her face, which was flushed red. Another CNA (V6) reported hearing R2 yell for help, entering R1’s room, and finding R2 at the foot of R1’s bed while R1 was hysterical and asking for him to be removed. The administrator (V1), who served as abuse coordinator, stated that the facility did not have a supervision/monitoring policy, despite facility policy stating a commitment to protect residents from abuse and to ensure staff have knowledge of individual resident care needs. These circumstances reflect a failure to adequately supervise and monitor R2, a resident with dementia and potential for aggression, resulting in physical abuse of R1.

Additional documentation showed that R1’s MDS reflected a BIMS score of 13/15, indicating she was cognitively intact, with diagnoses including bilateral sensorineural hearing loss, rheumatoid arthritis, gait abnormalities, and vitamin D deficiency. A progress note for R1 recorded that a CNA informed the nurse that R1 had been hit in the face by another resident, and that the nurse found R1 in bed crying, with redness to the left cheek and flushed face and neck. A corresponding progress note for R2 recorded that staff were informed R2 had hit another resident in the face. Staff interviews indicated that residents with dementia were generally monitored every 15 minutes according to one CNA, while another nurse stated residents with dementia were monitored every two hours, and that R2 could easily access R1’s room due to their proximity. The combination of R2’s known dementia and potential for aggression, the lack of a facility supervision/monitoring policy, and inconsistent descriptions of monitoring practices contributed to the failure to prevent R2 from entering R1’s room and physically abusing her.