F0610

E

Failure to Investigate Resident-to-Resident Abuse Incidents

Muncie, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct thorough and accurate investigations into multiple resident-to-resident abuse incidents involving one resident who repeatedly pushed other residents, resulting in falls and injury. Resident B, who had dementia, hypertension, major depressive disorder, and anxiety, had a care plan problem dated 12/25/25 indicating he might threaten to hit or physically attack other residents and might shove, hit, or scratch. Progress notes documented that on 12/14/25 he pushed another resident out of his personal space, causing the other resident to lose balance, and on 1/15/26 he reportedly shoved another resident causing a fall. On 1/23/26, Resident B pushed another resident against a hallway wall, causing a laceration to the right side of the resident’s head and bruising to her right shoulder, and that resident was transferred to the ER.

Resident E, with dementia, generalized anxiety disorder, and mild neurocognitive disorder, was care planned as at risk for falls and had an intervention to encourage her not to be in others’ personal space. A fall event note documented that she lost her balance and fell onto her buttocks after being pushed by another resident when she approached that resident in the hallway; the IDT fall review identified the root cause as her being in another resident’s personal space and implemented staff encouragement for her to avoid others’ personal space. Resident F, with vascular dementia, psychotic disorder with delusions, and anxiety disorder, was documented in a progress note as having fallen after being pushed by another resident, losing her balance and falling without injury; the root cause was identified as loss of balance after being pushed, and an intervention of placing a stop sign on the doorway of a room she preferred to wander into was noted.

Resident D, who had severe dementia, schizophrenia, anxiety disorder, and required a wheelchair and partial assistance for transfers, reported multiple incidents involving another resident. On one occasion, a CNA found him sitting on the floor between the bed and wheelchair, and he stated another resident pushed him from the bed; no injuries were noted. On another occasion, he reported that a “crazy man” punched him in the head and then pushed him out of the wheelchair, with no injuries found. An IDT note later described that he stated another resident came into his room and pushed him to the floor, and a stop sign was placed on his doorway to deter other residents from entering. Despite these documented resident-to-resident altercations and falls involving pushing by another resident, the facility’s investigation files provided by the Administrator did not contain abuse investigations for the incidents involving Residents E, F, and D, and the Administrator confirmed that all investigations for the past 60 days had been provided and acknowledged that the pushing incident between Resident B and Resident F had been reported to him.