F0600

G

Failure to Prevent Resident‑to‑Resident Physical Abuse in Dining Area

Austin, Texas Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse during a resident‑to‑resident altercation. On the date of the incident, a female resident with a history of CVA with hemiparesis, vascular dementia, bipolar disorder, major depressive disorder, chronic kidney disease, and other comorbidities was in the dining room waiting in line to see a speech therapist. Her MDS showed moderately impaired cognition (BIMS 9) and dependence on staff for toileting and lower body dressing. Staff reported that she had pre‑existing bruises on both arms from a prior hospitalization, and her care plan included an ADL self‑care performance deficit related to CVA with hemiparesis and an intervention for staff to observe her skin for bruising.

At the time of the incident, a male resident with severe cognitive impairment (BIMS 0), vascular dementia with mood disturbance, intermittent explosive disorder, expressive aphasia, and a history of striking another resident was also in the dining room. His care plan, last revised shortly after the incident, documented that he had previously struck another resident on an earlier date and again on the date of this event, with identified interventions such as analyzing triggers, increasing monitoring, psych medication review, and redirection when stressed. On the day of the altercation, staff observed that he became frustrated because the female resident, who had right‑sided weakness and moved slowly, was in his way and could not move quickly enough.

According to staff interviews, the male resident pushed the female resident’s wheelchair and then raised his hand and hit her on the right arm while she yelled “stop” and cried. A CNA reported hearing the female resident cry out “he hit me,” and a nurse stated that by the time she got up from the nurses’ station, the male resident was already hitting the female resident on her right arm, which was known to be painful due to spasms. Staff separated the residents. Subsequent assessments documented that the female resident was crying and tearful after the incident, described being shocked and scared, and reported fear of the male resident, stating she did not feel safe and would avoid him or seek staff if she saw him. Physical assessment documented intact skin with no new skin issues at that time, though bruising was present on both arms, with some bruising attributed to a prior hospitalization. The facility’s abuse prevention policy stated that each resident has the right to be free from abuse, including willful infliction of injury causing physical harm, pain, or mental anguish, and that the facility would provide oversight and monitoring to ensure residents are free from abuse, neglect, and mistreatment.