F0600

D

Failure to Protect Residents From Peer-to-Peer Physical Abuse

Kansas City, Missouri Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse, in two separate incidents. Facility policy dated 6/12/24 states that the facility is committed to protecting residents from abuse by anyone, including other residents, and defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish. The policy also states the facility will identify events, patterns, and trends that may constitute abuse and investigate them thoroughly. Despite this policy, surveyors identified two sampled residents who were not kept free from abuse when they were physically struck by other residents.

In the first incident, a resident with schizoaffective disorder, bipolar disorder, vascular dementia, severe cognitive impairment, and a documented history of exit-seeking and aggressive behaviors with staff and peers at a prior placement struck another resident. The aggressor resident had significant memory issues, mood swings, depression, and tended to stay away from others with slow verbal responses. The victim resident had PTSD, depression, anxiety, adjustment disorder, panic attacks, poor impulse control, poor insight and judgment, irritability, and required more supervision due to poor decision making and behaviors. According to the facility’s incident report, the aggressor resident approached staff requesting to smoke and was told it was not time; the victim resident also stated it was not time for a smoke break. As the victim resident walked away from a table outside the dining room, the aggressor resident hit the victim in the back of the head. The victim reported pain to the back of the head and forearm, stated that the aggressor hit him/her several times on the head, face, and arm, screamed for help, and tried to redirect the aggressor out of the room, expressing feeling scared around the aggressor and relief that the aggressor was gone.

Additional information from staff interviews further described the first incident. A CNA reported that another resident called out and the CNA then observed the aggressor resident in the victim’s room “beating” the victim’s head while the victim was in bed and the aggressor was standing. The CNA stated that after getting the victim out of bed, the aggressor came toward them, and the CNA instructed the victim to count to three so they could back up and run out of the room to get away from the aggressor. The Administrator acknowledged that an incident of abuse occurred when the aggressor struck the victim in the back of the head. The aggressor later stated that the victim had hit him/her on the cheek, so he/she hit the victim back in the stomach while inside the smoke room.

In the second incident, another resident with schizophrenia, psychosis, bipolar disorder with psychotic features, borderline personality disorder, severe cognitive impairment, mood lability, paranoid delusions, agitation, intrusiveness, and a history of medication non-compliance struck a peer with a chair. This resident had significant fixed delusional ideation, was preoccupied with being continuously raped, and exhibited labile mood, agitation, rapid pressured speech, paranoia, and internal preoccupation. The victim in this incident had schizophrenia, chronic paranoid schizoaffective disorder, alcohol dependence, polysubstance abuse, a long history of psychiatric treatment and LTC placements, legal problems associated with substance use, homicidal ideation, threatening behaviors, mood lability, agitation, depression, continual auditory and visual hallucinations (many command in nature), severe paranoia, and severe cognitive impairment. The victim required verbal direction for personal care, supervision due to disorganization, and monitoring of what the hallucinated voices were telling him/her to do.

According to the progress note and incident report, the aggressor resident walked into the dining room where the victim was sitting with staff nearby and was observed pacing without clear evidence of anticipated aggression. Without provocation, the aggressor quickly picked up a dining room chair and threw or struck the victim with it. The victim raised an arm to block the chair while staff verbally directed the aggressor to stop. The victim sustained a small pin-sized scratch above the right eye with some swelling and bleeding that stopped after cleaning; later observation showed a laceration above the right eye that was well approximated with redness and swelling. At the time of surveyor observation, the victim was alert to self but unable to be interviewed, and the aggressor was displaying behaviors and could not be interviewed, with the Assistant Administrator stating it was not safe to be around the aggressor. The DON, Assistant Administrator, Regional Care Plan Coordinator, and psychiatric NP all stated that the incident in which the aggressor struck the victim with a chair met the criteria for abuse. These two events demonstrate that the facility did not ensure that residents were free from abuse by other residents, as required by its own policy and regulatory standards.