F0600

G

Failure to Prevent Resident‑on‑Resident Physical Abuse Resulting in Facial Trauma

Phoenix, Arizona Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in significant facial trauma. One resident with dementia, moderate cognitive impairment (BIMS score of 8), behavioral symptoms, a history of falling, and hearing loss was care planned for behavior problems such as placing himself on the floor, banging his head, yelling, paranoia, refusing care and medications, verbal and physical aggression, territorial behavior in the dining room, and making false accusations. His care plan included anticipating his care needs before he became overly stressed and implementing interventions as needed to protect the rights and safety of others. On the day of the incident, he was seated in his wheelchair in the dining room watching television when another resident approached him.

The other resident, who was cognitively intact (BIMS score of 15) and had diagnoses including schizophrenia, mild neurocognitive disorder with behavioral disturbance, psychoactive substance use disorder, anxiety disorder, insomnia, suicidal and homicidal ideations, and schizoaffective disorder bipolar type, had a care plan for behavioral problems including self-isolation, aggression, and a history of suicidal and homicidal ideation. Interventions for this resident included intervening as needed to protect the rights and safety of others, approaching him calmly, diverting his attention, and removing him from situations as needed. A psychiatry assessment recommended maintaining firm boundaries regarding appropriate and acceptable communication and behavior and consideration of a two-person assist for safety and accountability. On the day of the incident, this resident approached the nurse at the medication cart asking to speak with the unit manager about paperwork, was informed the manager had left, stated he did not need assistance, and then walked into the dining room.

Shortly after entering the dining room, the cognitively intact resident approached the resident with dementia and asked about a blue folder. Due to hearing loss, the seated resident responded that he did not have the folder or said “what,” and the interaction quickly became confrontational. Two CNAs in the dining room observed the resident who had entered calmly become agitated and strike the seated resident with a closed fist. Staff reported that, due to the size and strength of the aggressor, it required significant effort to separate them, and the aggressor was able to strike the other resident multiple times (approximately five times) before they were fully separated. A nurse, alerted by CNA yelling, arrived after the residents had been separated and found the injured resident in his wheelchair with blood dripping from his nose, blood coming from his left ear, a hematoma near his left eyebrow, and blood on the floor and surrounding area, with his hearing aids in his hand.

The injured resident was transported to the hospital, where CT imaging revealed mildly displaced bilateral nasal bone fractures and a 1.5 cm laceration to the left ear that required suture repair. Upon return, he was noted to have a swollen nose, bruising around the nose and left eye, and later two black eyes, with ongoing bruising and discoloration documented in weekly skin assessments. He reported that his hearing aids were damaged by his attacker and stated he had been beaten up by another resident. The facility’s investigation, including staff interviews and review of the incident, concluded that the allegation of physical abuse was verified. The DON stated that the incident met the definition of physical abuse under the facility’s Abuse Guidelines policy, which defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and requires assessment and care planning for residents with behavioral problems to protect the rights and safety of others.