F0607

L

Failure to Define and Manage Resident‑to‑Resident Abuse, Leading to Unrecognized and Unreported Assaults

Norwalk, California Survey Completed on 03-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement abuse policies and procedures that clearly define all forms of abuse, including resident‑to‑resident abuse, which led to multiple resident‑to‑resident physical and alleged sexual assaults not being recognized, reported, or investigated as abuse. The facility’s written abuse P&P, incident management P&P, and related training materials explicitly limited abuse definitions to acts committed by someone other than another patient, and sexual abuse to employee‑patient contact or employee‑facilitated patient contact. As a result, staff, including the Standards Compliance Director, Standards Compliance Supervising RN, Program Director, RN Shift Lead, and other nursing staff, consistently stated that resident‑to‑resident physical or sexual assaults were not considered abuse and therefore did not trigger abuse investigations, SOC 341 completion, or 2‑hour reporting to CDPH.

One incident involved a resident with significant physical impairments, including absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating, and wheelchair dependence, who sustained a 1.2 cm laceration above the right eyebrow with bruising after being punched in the face while sleeping by another resident. The aggressor resident had schizophrenia, a criminal history of assault with force likely to produce great bodily injury, and was assessed as a moderate risk for violence against others. Staff documented that the aggressor stated he punched the other resident because the resident “tried to have sex with me,” and the injured resident reported the attack was unprovoked. Despite this, the incident was treated as a physical altercation rather than abuse, the alleged sexual component was not treated as sexual assault or abuse, no abuse investigation was conducted, and the report to CDPH was delayed until three days later because the facility did not consider resident‑to‑resident events to meet its definition of abuse. The covering psychiatrist did not evaluate either resident at the time and was unaware of the sexual abuse allegation, and there was no treatment plan or interventions in place to address the aggressor’s known aggressive behaviors or to protect other residents.

A second incident involved a resident with gastrostomy status, pulmonary fibrosis, nonfunctional ambulation, and a high risk for violence against others, who kicked another resident using a front‑wheel walker in the buttocks, prompting the second resident, who had unsteadiness on feet, blindness in one eye, and a healing femur fracture with a past history of danger‑to‑others behaviors, to turn and punch the first resident in the face three times. This event was documented in the interdisciplinary notes as a physical altercation in the day hall. The facility’s leadership confirmed that resident‑to‑resident abuse was not included in the abuse P&P and that there was no separate P&P addressing protection and prevention of resident‑to‑resident abuse. The altercation was not reported to CDPH within 2 hours but instead two days later, and the resident who retaliated did not receive medication changes or enhanced monitoring after the incident, despite later having another aggressive outburst toward staff.

A third incident involved two residents both assessed as moderate risk for violence against others, one with a back fracture, epilepsy, and a significant history of danger‑to‑others behaviors, and the other with a history of verbalizing thoughts of harming another resident. Staff heard yelling in the day hall and found the two residents in a verbal altercation when one resident struck the other, who reported being hit in the chin. The striking resident later stated he used a closed fist to touch the other resident’s chin to make him stop cursing and yelling. This event was also treated as a resident‑to‑resident altercation rather than abuse, resulting in delayed reporting to CDPH by two days and delayed completion of the SOC 341 until several days after the incident, instead of by the end of the shift. The psychologist later confirmed that one resident had an extensive history of verbal aggression with prior alleged physical altercations and no behavioral care plan, and that another resident’s behavioral care plan had not been updated in over a year despite aggressive incidents and stated intent to harm another resident. Across these incidents, the facility’s P&P, definitions, and staff training excluded resident‑to‑resident acts from the abuse framework, leading to failures in recognizing, preventing, investigating, protecting, and timely reporting abuse, and placing all residents at risk of unreported and unmitigated abuse.

On 3/5/2026, surveyors declared an Immediate Jeopardy related to the lack of written policies and procedures prohibiting and preventing abuse that included resident‑to‑resident abuse, and to staff competency in identifying, preventing, screening, investigating, protecting, and reporting abuse under F607.

Removal Plan

• Treat physical altercations, sexual allegations, possible mental or psychological abuse, and exploitation in the SNF area as potential abuse allegations.
• Complete an SOC 341 form for each allegation of an abuse incident.
• Verify completion of SOC 341 by the RN Health Services Specialist/Supervising Registered Nurse prior to the end of the shift.
• Update reporting of unusual occurrences related to possible abuse incidents to ensure compliance with the reporting requirement.
• Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within the required timeframe.
• Program VI manager on call/unit shift lead will notify CNS for HSS to complete reporting within the required timeframe.
• Issue a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting, clarifying resident-to-resident incidents must be treated as potential abuse, and including CMS SOM reference, recognition/identification, screening, prevention/protection measures, early intervention/behavioral monitoring expectations, investigation/documentation requirements, reporting requirements, and SOC 341 completion.
• Require SRN attestation that staff can verbalize understanding of the memo/education, track training via a tracking log, and provide clarification as needed to ensure staff understand the abuse screening and reporting process.
• Issue a written memorandum for all registry nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting.
• Provide training via memorandum to non-nursing clinical staff and ancillary staff on federal regulatory requirements related to abuse recognition, screening and reporting.
• Provide additional staff training regarding intervention protocols to enhance behavioral monitoring and intervention strategies for residents identified as high risk for behavioral escalation or aggression, including identification of high-risk residents, enhanced monitoring/supervision strategies, early interventions/de-escalation techniques, implementation of individualized behavioral interventions, documentation, and communication to the interdisciplinary team.
• Conduct an analysis of the physical environment, staffing, supervision, and resident assessment/care planning/monitoring to identify, correct, and intervene in situations where possible abuse, neglect, or misappropriation of resident property is more likely to occur.
• Update Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental or psychological abuse, sexual allegations, and exploitation as potential abuse, including expectations for abuse screening, investigations, and reporting requirements.
• Conduct an ongoing review of all incident reports involving resident-to-resident altercations or allegations to ensure SOC 341 reports are completed and reporting timelines are met.