F0600

G

Failure to Prevent Resident-on-Resident Physical Abuse in Shared Bathroom

Kansas City, Missouri Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse when another resident physically assaulted him/her in a shared bathroom. Resident #3 had a history of behavior problems, restlessness, agitation, aggressive behavior, and pacing, with diagnoses including schizophrenia, schizoaffective disorder, mood disorder, personality disorder, anxiety disorder, and depression. Despite these conditions and the use of one-on-one monitoring, Resident #3 was allowed to go into the shared bathroom unaccompanied while the assigned CNA sat in the hallway outside the resident’s room. Resident #3 entered the bathroom that connected to Resident #4’s room, where Resident #4 was already present and naked, and then physically attacked Resident #4, striking him/her multiple times with a fist.

Resident #4, who also had diagnoses of schizophrenia, anxiety, and depression but no documented negative behaviors, was cognitively intact and independent with most self-care. At the time of the incident, Resident #4 was in the bathroom without clothing when Resident #3 entered and began punching him/her in the back and the back of the head. Resident #4 later reported being hit three or four times, that it hurt, and that he/she was scared. Another resident in the room with Resident #4 witnessed Resident #3 throwing punches at the back of Resident #4’s head until staff intervened. The CNA assigned to one-on-one monitoring heard noises from the bathroom, then observed Resident #3 coming out of Resident #4’s side of the bathroom stating he/she had beaten the other resident up, and noted swelling and pain in Resident #3’s hand.

Following the altercation, RN A documented that Resident #4 reported being hit on the back and back of the head but denied pain at that time, and the nurse’s assessment found no visible swelling, discoloration, bruising, or drainage. However, Resident #4 later stated that the incident hurt and that he/she was scared, and described praying for a reason to live afterward. The facility’s records showed no pain medication was administered to Resident #4 on the date of the incident and no pain assessments were documented in the EMR. Resident #3 refused a full assessment before being sent to the hospital, where his/her guardian was later informed that Resident #3 had a fractured right hand attributed to the altercation. The primary care physician for both residents stated that the incident of Resident #3 attacking and punching Resident #4 was abuse and noted that it would have been better if Resident #3 had not shared a bathroom with another resident.

The facility’s abuse, prohibition, and intervention policy stated that each resident had the right to be free from abuse, defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Despite this policy, Resident #3, who was on one-on-one monitoring due to unpredictable explosive behaviors, was not kept within immediate reach of staff when going into the shared bathroom, allowing access to Resident #4 while he/she was naked and vulnerable. CNA A acknowledged not following Resident #3 into the bathroom and remaining outside the doorway, and RN A reported that Resident #3 would not allow staff in his/her room, leading to one-on-one supervision being conducted from the hallway rather than in close proximity. These actions and inactions resulted in Resident #3 being able to physically assault Resident #4, causing fear, pain, and mental anguish, and constituted a failure to ensure the resident’s right to be free from abuse.