F0600

G

Failure to Protect Resident From Assault by Known Violent Peer

Norwalk, California Survey Completed on 03-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a medically fragile resident from physical abuse by another resident who had been previously identified as a moderate risk for violence against others. Resident 1’s MDS showed he had an absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating needs, and required a wheelchair for ambulation. On observation, Resident 1 was seen in bed with a noticeable laceration and bruising above the right eyebrow, and he reported that another resident attacked him in his sleep without provocation. A nurse later observed dried blood above Resident 1’s eyebrow, and Resident 1 again reported that he had been punched in the face while sleeping.

Resident 2’s treatment plan documented diagnoses including schizophrenia and a criminal history of assault by means of force likely to produce great bodily injury, and an evaluation on 1/22/2026 identified Resident 2 as a moderate risk for violence against others. Staff interviews indicated that Resident 2’s medical condition had improved to the point that he was highly ambulatory and no longer medically fragile. The Registered Nurse Shift Lead stated she was not surprised by the incident because Resident 2 had attempted to punch a staff member in October 2025, and a prior recommendation from the state hospital indicated Resident 2 should be carefully monitored due to a demonstrated history of violent behaviors. Despite these known risks, Resident 2 was able to access Resident 1’s room and punch him in the face while he slept.

Subsequent documentation and interviews confirmed Resident 2’s aggressive behavior and intent. During an interview, Resident 2 admitted punching Resident 1 and stated he did so because he believed Resident 1 wanted to have sex with him. Physician progress notes recorded that Resident 2 told staff he was hearing voices to hurt others, that he had attacked a peer and caused injury, and that he would continue hitting people until he was discharged. The facility’s policies on reporting abuse and on treatment planning required that abuse not be tolerated and that treatment plans address individualized risks, including danger to others, and that mini-team conferences be held after episodes of aggression. The failure to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, despite documented risk factors and prior aggressive behavior, led to Resident 1 being physically assaulted and injured while asleep.