F0610

D

Failure to Thoroughly Investigate Resident‑to‑Resident Physical Altercation

Saint Louis, Missouri Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse arising from a physical altercation between two residents. The facility’s Abuse and Neglect policy requires that all allegations of abuse, including resident‑to‑resident altercations, be immediately reported to the Administrator and other appropriate agencies, and that an administrative investigation be completed with statements from all involved staff and residents, documentation of pertinent information, and identification of root cause. Despite this policy, the facility did not complete a comprehensive investigation after an incident in which two residents reported hitting each other.

Resident #1, who had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke, was documented in a nurse’s note as having an altercation with his/her roommate, Resident #2. The note described a verbal disagreement that escalated, with the nurse initially separating the residents and moving Resident #1 to the hallway, then later finding Resident #2 standing over Resident #1, yelling, after being called back because it was reported as a fight. Resident #1 requested hospital evaluation and voiced suicidal ideation, and management was notified. However, there was no care plan documentation regarding the altercation, and the medical record contained no evidence of a completed incident report or a documented administrative investigation as required by policy. In a later interview, Resident #1 stated that another resident hit him/her and he/she hit back.

Resident #2, who had no documented cognitive impairment and diagnoses including hypertension, Alzheimer’s disease, seizure disorder, schizophrenia, and depression, also had no care plan or medical record documentation of the altercation. Resident #2 reported that Resident #1 hit him/her in the chest. Another resident, Resident #8, cognitively intact with anxiety and schizophrenia, reported hearing two residents arguing and notifying an LPN, but stated no one had asked him/her about the incident before the survey interview. The LPN reported finding Resident #2 standing over Resident #1, being told by both residents that they hit each other, separating them, and notifying the on‑call ADON, but was not asked to write a statement. The ADON stated he/she was only told there was an argument, not a physical altercation, and the Administrator acknowledged not interviewing Resident #1 and not documenting interviews obtained from others. The DON stated the Abuse and Neglect policy was expected to be followed, including accurate information and gathering statements, but could not explain why this did not occur, resulting in a failure to conduct the thorough investigation required by facility policy.