F0600

G

Resident-to-resident altercation resulting in dental and head injuries

Moberly, Missouri Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse during a resident-to-resident altercation in a shared bedroom. Two residents with significant psychiatric and behavioral diagnoses were roommates and became involved in a conflict related to a vape pen. One resident, who was cognitively intact with diagnoses including schizophrenia, anxiety disorder, and paranoid schizophrenia, reported becoming angry after an interaction at the bedroom door and admitted to striking the roommate several times in the mouth and head. The other resident, who had a guardian and diagnoses including bipolar disorder, autistic disorder, ADHD, impulse disorder, and oppositional defiant disorder, reported attempting to talk calmly with the roommate and then being pinned against the door and punched in the head and face.

According to nursing progress notes and staff interviews, floor staff heard a shuffling sound and a call for staff around 12:20 A.M. and, upon entering the room, observed both residents behind the door with the aggressor pinning the other resident against the wall in the corner. As staff intervened to separate them, the aggressor reached over a staff member and struck the victim again. The aggressor later stated that the conflict began when the roommate had possession of the vape pen and that he/she became angry when the roommate allegedly hit him/her with the door or in the shoulder while he/she was trying to leave the room. The victim consistently reported that he/she did not hit or kick back at the roommate and that the roommate pinned him/her and began punching him/her in the head and face.

The victim sustained multiple documented injuries as a result of the altercation. Nursing notes described one lower front tooth broken out, another tooth loose, and a third tooth chipped, along with a small laceration inside the lower lip where the tooth was missing. Multiple red areas were noted on the sides and top of the head, including a darker, slightly swollen area at the left front hairline. The resident complained of head pain rated five out of ten and later required evaluation for unresolved dental pain, with a dental consultation recommending root canal and crown or extraction of two lower anterior broken teeth. The facility’s own abuse and neglect policy defined abuse to include resident-to-resident altercations and required that residents who allegedly mistreat another resident be removed from contact with the resident during the investigation, underscoring that the incident met the facility’s definition of abuse when one resident willfully struck another, causing physical harm and pain.

The facility’s investigation and documentation identified the aggressor as the resident who pinned the roommate and delivered multiple punches to the head and face, and the victim as the resident who sustained dental and head injuries. The psychosocial post-incident questionnaire completed for the aggressor recorded that the resident was the aggressor in the incident and acknowledged that he/she should not have hit the peer and should have left the vape pen in the smoke box. Staff accounts, resident statements, and clinical documentation collectively show that the altercation escalated from a disagreement over a vape pen and a conflict at the bedroom door, culminating in physical abuse that resulted in significant injury to the victim, thereby demonstrating the facility’s failure to ensure the resident was free from abuse as required by its policy and regulatory standards.