F0600

G

Failure to Prevent Repeated Resident-to-Resident Physical Abuse

Kansas City, Missouri Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and triggers. The facility’s own Abuse and Neglect Policy defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes hitting, slapping, punching, biting, and kicking. Across several incidents, residents with significant psychiatric and neurocognitive diagnoses engaged in physical altercations that resulted in injuries such as a lacerated lip requiring sutures, nasal fracture, and hand laceration. These events occurred in common areas such as smoke decks, patios, and halls, often in the presence of other residents and sometimes without staff immediately present.

One incident involved a cognitively intact resident with paranoid schizophrenia and a history of hitting behaviors, whose care plan identified triggers such as when someone was “mouthing off” and noted unused coping skills. This resident and another cognitively intact resident with schizophrenia and a history of agitation and threatening behavior had a physical altercation after a bump with a door, resulting in a facial laceration and lip injury requiring sutures. In another event, a resident with traumatic brain injury and moderate cognitive impairment placed a hand on the shoulder of a cognitively intact resident with multiple serious psychiatric diagnoses, who responded by punching the first resident in the chest. Witness accounts confirmed that the contact to the shoulder was not forceful, but the response was a hard punch that caused pain and sadness to the victim.

Additional altercations occurred between residents with complex psychiatric and behavioral profiles. One cognitively intact resident with schizoaffective and personality disorders entered another cognitively intact resident’s room and ate that resident’s food, leading to a fight in which both hit each other and one sustained a nasal fracture. Another cognitively intact resident pushed a cognitively impaired peer who was urinating on a smoke deck, after verbally telling the peer to stop; the pushed resident slipped in urine and scraped a hand on a brick wall, causing a laceration. On a smoking patio, a cognitively intact resident with bipolar disorder and intermittent explosive disorder refused to share a cigarette with another cognitively intact resident with schizophrenia and psychosis; the latter admitted to hitting the former multiple times in the head and face with a fist, causing the resident to fall to the ground.

Further, a cognitively intact resident with bipolar disorder, ADHD, intellectual disability, and a history of angry outbursts was involved in a separate altercation with another cognitively intact resident with bipolar disorder, PTSD, autism, and anger control issues. Conflicting statements indicated that one resident had been “messing with” or bullying the other and that both admitted to hitting each other, with witnesses describing one resident running toward the other and initiating contact, leading both to fall to the ground. Discoloration was noted on one resident’s neck, and another resident reported temple pain. Throughout these events, staff and resident interviews, written statements, and facility documentation consistently characterized the physical acts—punching, hitting, and pushing—as abuse, and leadership acknowledged that residents “could not go around hitting each other,” yet multiple episodes of resident-to-resident physical aggression occurred involving nine sampled residents.