F0600

E

Failure to Prevent Ongoing Resident-to-Resident Physical Abuse by Known Aggressor

Muncie, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from recurrent resident‑to‑resident physical abuse by one resident with known aggressive behaviors. Resident B, who had dementia with severe cognitive impairment and a documented history of shoving, hitting, scratching, and threatening to hit or physically attack other residents, repeatedly engaged in physical aggression toward other residents on the dementia unit. Progress notes documented numerous episodes of Resident B pushing other residents, throwing objects, yelling expletives, pacing into other residents’ rooms, pulling on wheelchairs, and becoming aggressive with staff attempting redirection. Despite these ongoing behaviors and an existing care plan problem identifying his risk for physical aggression, the clinical record lacked care plan interventions specific to mitigating the risk of Resident B engaging in resident‑to‑resident altercations.

Resident E, who had dementia and severe cognitive impairment, experienced two separate incidents in which she was pushed by Resident B. In the first incident, she was walking down the hall when another resident pushed her out of his personal space, causing her to lose balance and fall; the IDT identified the root cause as her being in another resident’s personal space and implemented an intervention to encourage her not to be in others’ personal space. In the second incident, she was walking past Resident B in the dementia unit dining room when he shoved her to the floor and kicked her in the abdomen. Witnesses, including a CNA and a housekeeper, described Resident B pushing her, causing a fall, and then kicking her while staff attempted to intervene. Although these events were documented and reported, the facility’s care planning for Resident B did not include specific interventions to prevent further resident‑to‑resident altercations.

Resident F, who had vascular dementia with behavioral disturbance and severe cognitive impairment, was pushed by Resident B while walking past his room, resulting in a fall to the floor. Staff accounts indicated that Resident F was known to wander and enter other residents’ rooms to offer snacks, and that Resident B had prior physical and verbal altercations with other residents, including Resident E. On the date of this incident, Resident B stepped forward from his doorway and pushed Resident F hard enough to propel her across the hallway into a wall and door, causing her to land on the floor. Similarly, Resident D, who had severe dementia, schizophrenia, and required a wheelchair for mobility, reported that another resident came into his room, punched him in the head, and pushed him from his wheelchair to the floor. Staff observed Resident B coming from Resident D’s room and then, shortly afterward, Resident B pushed Resident C, who had Alzheimer’s disease, into a door frame, causing a head laceration and shoulder bruising. These repeated episodes of physical aggression toward Residents C, D, E, and F occurred despite prior knowledge of Resident B’s behaviors and without individualized, documented care plan interventions aimed at preventing resident‑to‑resident abuse.

Resident C’s involvement further illustrates the pattern of unmitigated risk. She reported to CNAs that two men were fighting in a room, referring to an altercation involving Resident B. As staff attempted to escort her away, Resident B emerged from another resident’s room with fists balled, appeared angry, and advanced toward them. Staff placed Resident C in front of them and tried to walk away, but Resident B caught up, grabbed her, and pushed her into a door jamb. The ADON later described Resident B grabbing the back of Resident C’s head and slamming it against a metal door frame, resulting in a laceration to the right side of her head and immediate bruising to her right shoulder. These events, combined with prior documented incidents of Resident B pushing other residents and causing falls, demonstrate that the facility did not implement or document specific, individualized care plan interventions to address and reduce the risk of further resident‑to‑resident altercations involving Resident B, leading to repeated episodes of physical abuse of multiple cognitively impaired residents.

The facility’s own behavior/high‑risk peer review documentation acknowledged that Resident B had previous incidents of pushing other residents, including the 12/25/25 incident with Resident E and the 1/15/26 incident where he shoved another resident causing a fall. Staff interviews consistently described Resident B as becoming overstimulated around other residents, wandering into rooms, and exhibiting aggressive posturing and actions toward peers. Despite this pattern and the facility’s abuse prohibition policy requiring assessment, root cause analysis, IDT recommendations, and care plan updates to prevent further occurrences, Resident B’s clinical record did not contain care plan interventions specifically directed at mitigating his risk for resident‑to‑resident altercations. This lack of targeted, documented interventions in the face of known, escalating aggressive behavior toward Residents C, D, E, and F constitutes the core deficiency in protecting residents from abuse.