F0600

E

Failure to Prevent Resident-to-Resident Physical Abuse Involving Dementia and Agitation

Concord, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect four residents from physical abuse during two separate resident‑to‑resident altercations. In the first incident, a resident with dementia and behavioral disturbance (Resident 2), who was documented as able to make himself understood and understand others, and another resident with severe cognitive impairment (Resident 3, BIMS score 3/15) engaged in a physical altercation in the hallway between two nursing stations. Staff reported hearing screaming and, upon responding, observed Resident 3 in his wheelchair yelling at Resident 2. While one LVN attempted to redirect Resident 3 back to his room, Resident 2 struck Resident 3 in the head with his fist, and Resident 3 scratched Resident 2 on the left side of the neck with his fingernails, resulting in a one‑inch scratch with minimal bleeding for Resident 2 and a reddened area on the right forehead for Resident 3.

In the second incident, two roommates with dementia and agitation (Residents 4 and 5) were involved in a physical altercation in their shared room. Resident 4, who usually understood others and could usually make himself understood, approached an LVN early in the morning visibly upset and reported that his roommate had hit him while he was sleeping. The LVN observed a superficial cut on the top of Resident 4’s head, a small scratch on the right cheek, and scratches on the right hand and left forearm, all with slight bleeding. When staff went to assess Resident 5, they found him out of bed, pacing angrily in the room, and noted a wound on the left side of his face; when the LVN attempted to approach using hand gestures, Resident 5 moved toward the doorway aggressively, gestured for the LVN to leave, and slammed the door, though the LVN was able to observe a scratch on his upper lip.

The facility’s Director of Nursing stated that CNAs are updated on resident care plans during shift‑change huddles and that individualized, person‑centered care plans are supposed to be in place for all residents, particularly those with dementia who may experience agitation and aggression. During review of care plan reports for the involved residents, the DON acknowledged that Resident 2 did not have a care plan for dementia. The DON further stated that the altercation between Residents 2 and 3 could have been avoided if Resident 2 had a dementia care plan in effect. The facility’s written policy on resident rights states that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, but the events described show that the facility did not prevent physical abuse between residents in these cases.