F0609

D

Failure to Report Resident-to-Resident Altercation With Injuries

Independence, Missouri Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report a resident‑to‑resident altercation that resulted in injuries, as required by its Abuse Prevention and Prohibition Program. The policy, revised 10/24/22, required the facility to report any incident of abuse that resulted in significant resident injury within two hours to all required entities, including the Department of Health and Senior Services. On 3/5/26 at approximately 11:30 A.M., an occupational therapy assistant (OTA) heard yelling from a resident’s room and found two residents on the floor, with one on top of the other, both punching each other. The OTA called for help, and a CNA assisted in separating the residents. The assistant director of nursing (ADON) assessed both residents and identified that one resident had a small cut on the left eyebrow, a small red area on the left side of the face, and the beginning of a bruise under the left eye, while the other resident had a small cut below the lip.

Both residents involved had dementia and psychiatric diagnoses. One resident had unspecified dementia without behaviors, auditory hallucinations, and a psychotic disorder with hallucinations. The other resident had unspecified dementia with agitation, anxiety, a psychotic mood disorder, and a history of stroke. Staff, including the OTA and CNA, immediately reported the incident to the LPN and ADON, and the ADON then informed the Administrator, who was the abuse coordinator responsible for reporting. Despite being notified of the altercation and the injuries, the Administrator determined the event was territorial in nature, believed neither resident intended harm, and concluded it was not abuse. Based on this judgment, the Administrator did not report the incident to the required authorities, resulting in noncompliance with the facility’s abuse reporting policy.