F0600

G

Resident-to-resident assault following unmanaged psychotic and delusional behaviors

Raytown, Missouri Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse when a cognitively impaired resident with cerebral palsy and sequelae of cerebral infarction was struck in the face by a roommate while sleeping. The assaulted resident had been admitted days earlier and had an MDS indicating cognitive impairment, with a care plan noting impaired cognitive function/dementia and impaired thought processes with neurological symptoms. In the early morning hours, this resident approached the south nurses’ station with visible bleeding from the nose, appeared upset, and reported that the roommate had woken them, proclaimed they were the devil, and struck them in the face while they were in bed. The charge nurse observed bleeding, assisted with cleaning the face, applied ice, and administered PRN Tylenol, and the resident was placed at the nurses’ station for close observation.

The aggressor resident had a documented long-standing history of serious psychiatric diagnoses, including schizophrenia (paranoid type), schizoaffective disorder (bipolar type), antisocial personality disorder, personality disorder, insomnia, and positive symptoms of schizophrenia such as auditory and visual hallucinations, delusional thinking, and psychosis. The PASRR/MI Level II evaluation documented paranoid ideation, delusional thinking, reality testing problems, and suspiciousness of others, including not trusting other residents. Progress notes referenced complaints of spiritual battles, metaphysical spears, and a foreign presence attempting to steal money, as well as increased delusions and hallucinations when antipsychotic medications such as Risperdal or Clozaril were decreased, and poor response to Zyprexa. The resident’s care plan identified a behavior problem of potential aggression related to spiritual beliefs that others may be the devil or working with the devil, with interventions including administering psychotropic medications as ordered and monitoring for side effects and effectiveness. A recent GDR of psychotropic medication had been attempted and failed shortly before the incident.

On the night of the incident, progress notes for the aggressor resident documented that, following the altercation, the resident was alert but exhibited delusional and religiously preoccupied speech, stating that the event was about the roommate being the devil, that they had been awake for days trying to trap the devil’s power, and that they were trying to do the right thing. The resident reported believing the roommate was using the devil’s power and described paranoid and delusional content consistent with prior documented symptoms. The assaulted resident’s trauma-informed care documentation indicated they had been physically assaulted, and a skin check showed a laceration to the inner lip and minor swelling to the left eye. An emergency provider report later documented head and facial contusions, intraoral laceration, left facial and periorbital soft tissue swelling, and a 2.5 cm inner lower lip laceration requiring sutures. A police report recorded the victim’s account that the roommate approached while they were in bed, made a sexual statement, and then punched them multiple times in the face while repeatedly shouting, “I’m the devil,” until the victim was able to push the aggressor away and escape to the nurses’ station. Facility leadership, including the DON and Administrator, later stated they did not anticipate such an event, did not believe the aggressor acted with intent, and did not consider the incident to be abuse, despite the facility’s abuse policy defining abuse to include resident-to-resident altercations and physical abuse such as hitting and punching.