F0689

D

Failure to Adequately Supervise Residents Resulting in Resident‑to‑Resident Physical Altercation

Saint Petersburg, Florida Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent a resident‑to‑resident physical altercation. On the date of the incident, one resident with dementia, behavioral disturbances, and a history of physical aggression approached another resident who was seated in a wheelchair near the nursing station and struck him on the right side of the face. Staff present at the nursing station, including an LPN and a CNA, were seated and charting when the aggressive resident walked down the hallway from the conference room area, stopped near the other resident, and delivered the punch. The incident was directly observed by at least one staff member, who reported seeing the blow and then intervening to separate the residents.

The resident who was struck had multiple psychiatric diagnoses, including psychotic disorder with hallucinations due to a known physiological condition, generalized anxiety disorder, paranoid schizophrenia, recurrent moderate major depressive disorder, and pseudobulbar affect, and had a BIMS score of 9/15 indicating moderate cognitive impairment. His care plan identified him as a resident‑to‑resident non‑aggressor and documented numerous behavioral issues such as disruptive noises, wandering and sitting in various places in the halls, discarding food from meal trays, and calling 911 inappropriately, as well as impaired communication due to cognition. Progress notes and a psychiatry note documented that he was the victim in the altercation, that he denied pain and did not understand why he had been hit, and that he appeared at psychosocial baseline after the event.

The resident who initiated the physical contact had diagnoses including unspecified dementia with behavioral disturbances, recurrent mild major depressive disorder, other specified persistent mood disorders, and generalized anxiety disorder, with a BIMS score of 11/15, also indicating moderate cognitive impairment. His care plan documented a history and potential for physical aggression related to dementia and poor impulse control, including prior incidents such as punching and breaking a bathroom mirror, striking a peer with a wet floor sign, slapping a peer, grabbing a peer by the wrist, pulling a fire alarm, attempting to remove a TV, and wandering into peers’ rooms to take items. Staff interviews confirmed that this resident frequently walked around, stole food, and entered other residents’ rooms, while the victim resident also walked the halls, yelled, and screamed. Despite these known behaviors and the facility’s abuse policy requiring protection from physical and psychosocial harm and increased supervision of residents, both residents were in a common area near the nursing station at the time of the incident without effective supervision that prevented the aggressive resident from approaching and striking the other resident.