F0600

G

Failure to Assess, Document, and Care Plan Behavioral Triggers Leading to Resident‑to‑Resident Assault

Columbia Heights, Minnesota Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident (R1) had diagnoses including primary hypertension, traumatic subdural hemorrhage with loss of consciousness, and non‑Alzheimer’s dementia, with a comprehensive MDS indicating severe cognitive impairment and no documented behaviors. R1’s care plan identified her as a categorically vulnerable adult who required substantial/maximal assistance with transfers and toileting, and directed staff to monitor for emotional distress or mood/behavior changes and to provide a safe, consistent environment with supervision as needed. On the evening of 3/15/26, while R1 was seated in the TV room, another resident (R2) struck her in the face, causing her to fall from her chair. Staff were present and witnessed the event, which was described as unprovoked based on staff accounts.

R1 sustained swelling to the eyebrow, a lip laceration, and was transferred to the ED, where imaging showed a large left forehead hematoma with associated swelling, a lip laceration, and a closed nasal bone fracture. Interviews with family confirmed that R1 had been sitting in the TV area with other residents when R2, seated behind her, suddenly punched her, resulting in a broken nose and forehead hematoma. Multiple nursing assistants reported that R1 frequently spoke loudly to the television or called out to staff, and that R2 became agitated or angry in response to these loud vocalizations. Staff described that when R2 was agitated, he would show facial expression changes and speak in Spanish, and that they would sometimes separate him from other residents or redirect him to his room during these episodes. However, these observations and known triggers were not documented in the medical record.

R2 had diagnoses including disorientation, dementia, and behavioral symptoms, with an MDS indicating moderate cognitive impairment and no behaviors identified, and was independent with transfers and ambulation. R2’s ADL care plan directed staff to monitor for emotional distress or mood and behavior changes, including agitation/aggression, but did not identify specific agitative or aggressive behaviors or triggers. A psychiatric assessment recommended that the care team track and monitor R2’s behavioral dysregulation to identify triggers and beneficial interventions, and advised the IDT to review findings and develop a behavior support plan if agitation persisted, with emphasis on maintaining appropriate supervision, reinforcing boundaries, and objectively monitoring behaviors. Record review from 3/11/26 through 3/15/26 showed no evidence that these recommendations were implemented: there was no tracking or monitoring of behavioral dysregulation, no identification of triggers, no documentation of interventions attempted, and no behavior support plan developed. Staff interviews revealed that nurses and aides were aware of R2’s agitation, prior altercations, and specific triggers related to loud environments and R1’s vocalizations, but they were unsure where to document behaviors, were unaware of any behavioral support plan, and did not report that the IDT had reviewed or addressed these behaviors. This lack of assessment, documentation, and care planning for R2’s known behavioral issues and triggers led to the failure to protect R1’s right to be free from physical abuse.