F0600

D

Failure to Prevent Repeated Resident-to-Resident Physical Abuse by a Known Aggressive Resident

Aurora, Colorado Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident, despite documented patterns of aggressive behavior. Facility policy required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, including verbally and physically aggressive behavior and wandering into others’ rooms or space. Resident #8 had dementia with severe cognitive impairment and was independently ambulatory. Prior to the first substantiated abuse incident, multiple nursing and behavior notes documented that Resident #8 was restless, impulsive, wandered and interfered with other residents’ care, became irritated and agitated when redirected, and was verbally and physically aggressive toward staff. Specific episodes included pulling another resident in a wheelchair, hitting a CNA in the chest, attempting to throw a walker at a nurse, getting very close to other residents and preventing them from doing daily activities, and becoming verbally and physically aggressive when redirected.

Resident #8’s behavior care plan, initiated in January and revised in February, identified depression, insomnia, agitation, anxiety about going home, refusal of care, verbal aggression, and physical aggression toward staff, including throwing objects and attempting to hit staff. Staff had also observed Resident #8 putting hands on other residents in a non-aggressive manner to direct them and noted that she could be difficult to redirect. The care plan included interventions such as one-on-one supervision, explaining procedures, allowing time to adjust to changes, intervening to protect the rights and safety of others, removing the resident from situations, taking her to alternate locations, observing for behavior episodes and underlying causes, and providing appropriate activities. However, one-on-one supervision was not in place prior to the first abuse incident and was only implemented after that event, even though Resident #8 had exhibited multiple aggressive behaviors toward staff and other residents in the weeks leading up to the incident.

On 2/24/26, while Resident #8 was at the exit doors pushing on them, Resident #9, who had dementia with severe cognitive impairment, physical behaviors toward others, and wandering, approached the same area. Unprovoked, Resident #8 pushed Resident #9 forcefully against the exit doors, then followed her as she tried to walk away, hitting her back and upper arms multiple times and pulling a room door closed while stating, “If you are going to behave like a baby, you are going to stay there.” RN #1 witnessed the event as it was occurring and intervened, with a CNA responding to the commotion. Resident #9 was assessed and had no injuries or noted change in mood or behavior, and she was unable to recall the incident. The facility substantiated this as physical abuse.

Despite this substantiated abuse and the prior documented aggressive behaviors, Resident #8 continued to exhibit problematic behaviors, including throwing water at another resident and touching other residents and staff. On 2/28/26, a second substantiated abuse incident occurred involving Resident #12, who had anxiety, dementia, a cognitive communication deficit, and was cognitively intact per MDS with verbal behaviors toward others. Resident #12 reported that she found Resident #8 in her room sitting on her bed and told her to leave, pointing to her name on the wall to show it was her room. Resident #8 became upset, grabbed Resident #12’s blanket, and slapped her on the left cheek. A nurse heard Resident #12 calling for help, entered the room, and observed Resident #8 holding the blanket while Resident #12 reported being slapped. Resident #8 admitted to slapping Resident #12, stating that she was “being a brat.” Resident #12 was found to have redness on her left cheek measuring 2.5 cm by 1 cm and reported that her cheek hurt for a couple of days. The facility substantiated this second incident as physical abuse.

Staff interviews further described Resident #8 as impulsive, unpredictable, verbally and physically aggressive, challenging to redirect, and exhibiting exit-seeking behaviors. The social services director and CNA #3 both indicated difficulty identifying triggers for Resident #8’s behaviors, and CNA #3 reported being hit by Resident #8 while attempting to redirect her from entering another resident’s room. The DON and NHA confirmed that Resident #8 had been aggressive toward other residents, that she had been moved between units, and that the facility was still trying to identify her behavior triggers. Overall, the documented pattern of aggressive behavior, the care plan identifying risk to others, and the occurrence of two substantiated resident-to-resident abuse incidents demonstrate that the facility did not effectively implement and maintain interventions necessary to keep Resident #9 and Resident #12 free from abuse by Resident #8.