F0609

E

Failure to Self-Report Resident-to-Resident Physical Altercations as Alleged Abuse

Stow, Ohio Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely self-report multiple resident-to-resident physical altercations to the State Agency (SA) as allegations of abuse, in accordance with federal requirements and the facility’s own Abuse, Neglect and Exploitation policy. For one incident, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, and obesity, who had a documented history of verbal and physical aggression, pushed and struck another cognitively impaired resident in the abdomen after the second resident slammed a dining room chair into a table and attempted to push the first resident’s wheelchair. The second resident then struck the first resident on the back of the head. Nursing notes and internal incident reports documented the altercation, assessments, and that no injuries were observed. The Administrator and DON acknowledged that an internal investigation was conducted but confirmed that no Self-Reported Incident (SRI) was filed because there was no injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s abuse flow sheet indicating that the reasonable person concept should be applied to such physical altercations.

In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst. They found the cognitively impaired resident who had a history of aggressive behaviors sitting on the other resident’s bed, while the room’s occupant, who had Alzheimer’s disease with late onset, psychosis, vascular dementia, and other psychiatric and behavioral diagnoses, was in a wheelchair eating dinner. The room’s occupant reported that the aggressive 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 separated and that no injuries were observed. The Administrator and DON again stated that an internal investigation was completed but that no SRI was submitted to the SA because there was no injury and they believed the residents involved did not have the ability to intend harm or cause mental anguish, even though the facility’s policy and abuse flow sheet defined physical abuse to include hitting and required reporting of alleged violations within specified timeframes.

Another incident involved a resident with dementia and extensive behavioral symptoms, including exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, and other disruptive behaviors, striking a severely cognitively impaired resident with multiple medical conditions, including vascular dementia, chronic obstructive pulmonary disease, heart disease, and chronic kidney disease. According to the Incident Audit Report and a Physical Aggression Form, a CNA witnessed the aggressive resident hit the other resident in the left side of the chest with her hand in a common area and immediately redirected the aggressor. The nurse assessed the struck resident, documented no redness or bruising, and recorded vital signs within normal limits, though the resident stated that it hurt and did not know why she had been hit. The physician and family were notified, and monitoring for pain or bruising was ordered. The DON stated that no SRI was completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s Abuse, Neglect and Exploitation policy defining physical abuse as including hitting and requiring immediate reporting of alleged violations involving abuse to the SA within the required timeframe.

Across these events, record review, interviews, and policy review showed that the facility consistently treated these resident-to-resident physical altercations as internal incidents without reporting them as allegations of abuse to the SA. The facility’s abuse policy and undated abuse flow sheet specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and that alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The abuse flow sheet also clarified that having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions and directed staff to use the reasonable person concept to determine psychosocial impact. Despite this, the Administrator, DON, and RN/VPOC acknowledged that SRIs were not filed for these incidents because they focused on the absence of observed injury and their belief that the residents lacked intent, rather than on the willful nature of the physical acts and the reasonable potential for injury or mental anguish as required by their own policy.