F0610

D

Failure to Report and Investigate Resident-to-Resident Altercation per Abuse Policy

Saint Louis, Missouri Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow the facility’s abuse and neglect policy when a resident-to-resident altercation occurred and was not reported to Administration, preventing a thorough abuse investigation. The policy required that all allegations or suspicions of abuse, including resident-to-resident physical abuse and injuries of unknown origin, be reported immediately to the Administrator and appropriate agencies, and that an administrative investigation be completed with staff and resident statements, record review, and care plan updates. On the date of the incident, nursing documentation showed that one resident (Resident #1), who had moderate cognitive impairment, anemia, and ESRD, was sitting in a television area when another resident (Resident #2) was seen hitting him/her with a walking cane, causing a slight bruise/cut under the left eye. The area was cleansed, treated with triple antibiotic ointment, and bandaged, and the DON, ADON, and Resident #1’s family were notified.

Nursing notes for Resident #2, who had no documented cognitive impairment or behaviors but carried diagnoses including anemia, CHF, HTN, and Alzheimer’s disease, documented that he/she was seen in the television area hitting another resident with a cane, after which the residents were separated and Resident #2 was taken to the nursing station. A message was left for Resident #2’s family and the DON and ADON were made aware. Two days later, Resident #1 complained of a headache, requested to go to the hospital to be evaluated following the altercation, and was transferred; the family and physician were notified, and the DON was made aware. Despite these events, neither Resident #1’s nor Resident #2’s care plans contained documentation regarding the resident-to-resident altercation.

Interviews and record review showed that the facility did not initiate or complete the required administrative abuse investigation. RN A reported overhearing a commotion, hearing another resident (Resident #4, with moderate cognitive impairment) question Resident #2 about hitting Resident #1, and then observing a cut under Resident #1’s left eye; RN A separated the residents, took Resident #2 to the nursing station, and notified the DON, physician, and families, but was not asked to write a statement. Resident #4 later stated that Resident #1 had been watching television when Resident #2 approached and began hitting Resident #1 with a cane without any exchange of words; Resident #4 was not interviewed or asked for a written statement by facility staff. The DON stated she was told that Resident #2 had a fall and that the cane accidentally hit Resident #1, reviewed only Resident #1’s notes, did not review Resident #2’s notes, did not obtain statements, and did not conduct a full investigation. The Administrator reported she was not informed of the altercation, and both she and the DON acknowledged that the incident should have been reported to the Administrator and to the state agency within two hours and investigated thoroughly, as required by the facility’s abuse policy.