F0600

D

Failure to Investigate and Address Resident-to-Resident Abuse Involving Cognitively Impaired Residents

Edgerton, Wisconsin Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to follow its own abuse, neglect, and exploitation policy after a resident-to-resident altercation. The facility’s policy requires prevention of abuse through identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as immediate investigation and protection of residents when abuse is suspected or reported. In this case, a resident with a history of aggressive behaviors toward staff and other residents was known by staff to be verbally and physically aggressive, including prior incidents involving another resident. Despite this history, there was no evidence of effective interventions or monitoring to prevent further resident-to-resident conflict.

The incident at issue occurred when two residents in wheelchairs became entangled in a hallway, and one resident slapped the other. A witnessing resident reported the event immediately to a CNA, who separated the residents and informed an LPN. The LPN assessed the slapped resident for red marks, reported the incident to the then-ADON and to the NHA, and informed the resident’s family member who arrived at that time. However, the LPN did not document the incident, did not obtain vital signs, and did not perform further assessment of either resident. The LPN was not aware of any new interventions being implemented, and nothing was placed on the 24-hour board or communicated in subsequent shift reports to guide staff in preventing recurrence.

Multiple staff interviews confirmed that the aggressive resident had a pattern of combative and verbally aggressive behavior toward staff and residents, including a prior incident of hitting another resident. Staff also reported that no new interventions were added to CNA care guides or communicated after the altercation, despite the facility’s policy requiring identification, care planning, and monitoring of residents with behaviors that might lead to conflict. The NHA acknowledged being informed that a resident had slapped another resident and that this type of incident should be investigated, documented, and potentially reported to the state. Nonetheless, the NHA did not document the event, did not interview the involved staff or other residents, and did not conduct a formal investigation. The NHA relied on a later conversation with the witnessing resident, who described the contact as a light tap, and no further follow-up with the involved residents occurred. As a result, the facility did not ensure that the resident was free from abuse by another resident and did not carry out the required investigative and protective steps outlined in its abuse policy.

The residents involved both had severe cognitive impairment as documented by BIMS scores of 02 and 00, and diagnoses including paranoid schizophrenia, unspecified dementia with mood disturbance, major depressive disorder, and Down syndrome. One resident’s care plan identified impaired decision-making related to psychiatric and cognitive diagnoses and directed staff to allow decision-making while ensuring the safety of the resident and others. Despite these known conditions and behavioral risks, there was no evidence that the facility updated care plans or implemented specific behavioral or supervision interventions following the altercation. The family member of the slapped resident reported not being contacted by the facility after the initial notification to explain what would be done to prevent future incidents and expressed concerns that the aggressive resident entered other residents’ rooms and took items. Overall, the facility’s inaction and lack of documentation, investigation, and care plan modification following a reported resident-to-resident slap constituted a failure to protect a resident from abuse and to follow established abuse prevention and investigation procedures.