F0607

E

Failure to Report Resident‑to‑Resident Physical Altercations as Abuse Allegations

Stow, Ohio Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse policy by timely reporting multiple resident‑to‑resident physical altercations as allegations of abuse to the State Agency. In one series of incidents, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, obesity, and documented behavioral symptoms including verbal and physical aggression, wandering, rummaging, and taking others’ belongings was involved in a physical altercation with another resident who also had Alzheimer’s disease, dementia with agitation, depression, anxiety, and wandering and aggressive behaviors. Nursing notes and internal risk reports documented that one resident slammed a dining room chair into a table, the other resident pushed him in the abdomen, and the first resident then struck the other on the back of the head. Staff separated the residents, assessed them, and documented no injuries, and internal incident reports were completed. However, the Administrator and DON confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s policy and abuse flow sheet referencing the reasonable person concept and the need to report resident‑to‑resident physical altercations that could cause injury, pain, or mental anguish.

In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst and found the cognitively impaired, wandering resident sitting in his wheelchair eating dinner while the aggressive resident was on the bed. The resident in the wheelchair reported that the other resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were immediately separated, no injuries were observed, and notifications within the facility were made. The resident who reported being punched had Alzheimer’s disease with late onset, unspecified psychosis, vascular dementia, personality disorder, anxiety disorder, and wandering and aggressive behaviors documented on the MDS and care plan. Despite the allegation of being punched in the face and the facility’s written policy defining physical abuse to include hitting and punching and requiring immediate reporting of alleged violations involving abuse, the Administrator and DON again confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents involved could not intend to harm or cause mental anguish.

Another incident involved a resident with dementia, delusions, severe cognitive impairment, and extensive behavioral symptoms such as exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, grabbing, kicking, hitting, pushing, cursing, anger, and agitation, who struck another severely cognitively impaired resident with multiple medical conditions including vascular dementia, COPD, heart disease, chronic kidney disease, malnutrition, and pain. An incident audit report and a physical aggression form documented that a CNA witnessed the aggressive resident hit the other resident in the left side of her chest with her hand in a common area, immediately redirected the aggressor, and notified the nurse. The nurse assessed the struck resident, documented no redness or bruising, obtained vital signs, and recorded that the resident stated it hurt but did not know why she had been hit. The physician and family were notified and monitoring was ordered. The DON stated that a self‑reported incident was not completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s abuse policy defining physical abuse to include hitting and requiring reporting of alleged violations involving abuse to the State Agency within specified timeframes. Across these events, the facility conducted internal investigations and documentation but did not treat the resident‑to‑resident physical altercations as reportable abuse allegations under its own policies and procedures.