F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse During One-on-One Monitoring

Pasadena, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident despite known risks and existing one-on-one monitoring orders. Resident 1, who had moderately impaired cognitive skills and required extensive assistance with ADLs, was in a hallway near the patio area on 3/9/2026 when an altercation occurred with Resident 2. Resident 1’s records showed diagnoses including encephalopathy, anxiety disorder, and schizoaffective disorder. At the time of the incident, Resident 1 approached Resident 2 in a wheelchair, said “excuse me,” and then made a verbal comment reported by staff as “Fuck you!” directed at Resident 2. Immediately afterward, Resident 2 punched Resident 1 in the face, causing a superficial skin tear measuring 0.4 cm on the left upper lip with slight bleeding.

Resident 2’s records indicated diagnoses including iron deficiency anemia, paranoid schizophrenia, and vascular dementia, with moderately impaired cognitive skills and a need for supervision or assistance with several ADLs. Resident 2 had a documented history of aggressive behavior and prior physical interaction with another resident. His care plan, revised on 2/25/2026, identified him as being at risk for stress-related suicidal ideation and aggressive behavior, with interventions that included moving him closer to the nurse’s station, placing him on one-on-one sitter, closely monitoring him when in an aggressive posture, anticipating care needs, intervening to protect the rights and safety of others, and restricting his access to other residents for safety. A physician’s order dated 2/17/2026 required one-on-one monitoring for Resident 2.

On the day of the incident, CNA 1 was assigned to provide one-on-one monitoring for Resident 2 and was responsible for supervising his behavior and ensuring his safety. CNA 1 was standing at a clothes rack selecting clothing for Resident 2 while Resident 2 sat in his wheelchair next to her. CNA 1 reported that her attention was on the clothes rack and that she had clothes in her hands when Resident 1 approached and exchanged words with Resident 2. Multiple staff interviews, including with the DON, DSD, and another CNA, confirmed that one-on-one monitoring required continuous visual attention and that residents on such monitoring should not be left unsupervised or unwatched because of the risk of unexpected movements and aggression. The DON acknowledged that CNA 1 was not watching Resident 2 at the time of the incident and stated that if CNA 1 had been watching him, the incident between the two residents could have been prevented. This lapse in supervision allowed Resident 2 to punch Resident 1, resulting in physical injury and possible psychosocial harm, and constituted a failure to protect the resident’s right to be free from abuse as required by the facility’s Abuse Prevention Program policy.