The October 16 fight at The Haven of Arcola involved two residents with vastly different mental capacities. One resident was described by staff as alert and oriented to person, place, time and situation. The other was characterized as confused and "in her own world."
The altercation began around 2:20 PM when the confused resident wheeled past and grabbed onto the other resident's wheelchair armrest. The alert resident became upset, yelled, and then slapped the confused resident in the right hand three times "reprimanding her like you would a child," according to a certified nursing assistant who witnessed the incident.
The alert resident later told federal inspectors that the confused resident "gets in people's rooms and sleeps in their beds and the facility hasn't done much about it." The resident claimed to have acted in retaliation, saying the confused resident hit first, but witnesses did not support that account.
Staff filed a serious injury incident report with the Illinois Department of Public Health on October 23, a week after the altercation. The state report documented that the alert resident "open handed smacked" the confused resident on the right upper arm and noted the claim of retaliation that witnesses could not verify.
But when federal inspectors arrived in November and examined both residents' electronic medical records, they found no documentation of the October 16 incident in either file.
The nursing assistant who witnessed the fight confirmed the details to inspectors on November 17. The witness described the incident as happening between 2:00 PM and 2:30 PM, with the alert resident's hit being intentional. The confused resident had simply wheeled past and grabbed the wheelchair armrest before being struck three times.
When inspectors asked the licensed practical nurse on duty that day where the incident was documented in the medical records, the nurse referred them to the director of nursing, saying the director "took over the incident." The LPN said the only documentation made was noting that the alert resident was placed on initial constant supervision, which was later changed to 15-minute checks.
The director of nursing confirmed to inspectors that resident-to-resident altercations are documented in risk management files but acknowledged this incident was not documented in either resident's electronic medical record. The director said the LPN who was the alert resident's nurse that day would have made notifications to family and physician, "which she usually documents in a progress note."
The director also said a registered nurse may have notified the confused resident's family and physician, and "all of this would be documented in risk management."
When inspectors spoke with the facility administrator, they received conflicting information. The administrator stated that resident-to-resident altercations are documented in risk management but said they thought staff had documented the incident in the electronic medical record in a progress note.
The facility's own abuse prevention policy requires that all incidents be documented, "whether or not abuse occurred, was alleged or suspected."
Federal inspectors found that the nursing home failed to maintain proper medical records for both residents involved in the altercation. The violation affects the facility's compliance with accepted professional standards for medical record keeping and resident information safeguarding.
The alert resident told inspectors there had been previous physical contact with the confused resident on an unidentified date. "She tried to go into my room, she banged on my arm, so I banged her back in the arm," the resident explained.
Staff described the confused resident as someone who wanders into other residents' rooms and beds, a behavior that appears to have created ongoing tension. The alert resident expressed frustration that "the facility hasn't done much about it."
The nursing assistant who witnessed the October incident has worked at the facility long enough to know both residents well. The witness described the alert resident as someone who "knows staff" and remains cognitively intact, while characterizing the confused resident as living "in her own world."
The October 16 altercation resulted in immediate supervision changes for the alert resident, moving from constant supervision to checks every 15 minutes. However, these interventions were not documented in the resident's medical record where future caregivers and medical professionals would expect to find such critical information.
The facility reported the incident to state regulators as required by Illinois law for serious injuries in long-term care facilities. The state report included details about the physical contact, the claim of retaliation, and the witness accounts that contradicted that claim.
But the gap between state reporting and medical record documentation creates a significant problem for continuity of care. Medical records serve as the primary communication tool between healthcare providers, family members, and future caregivers who need complete information about incidents affecting residents.
The missing documentation affects both residents. For the alert resident, the medical record lacks information about a behavioral incident that required increased supervision. For the confused resident, there is no record of being struck by another resident, information that could be relevant to future care planning and safety measures.
Federal regulations require nursing homes to maintain medical records that meet accepted professional standards. These standards include documenting significant incidents, injuries, and behavioral issues that affect resident care and safety.
The facility's administrator and director of nursing provided inconsistent explanations to inspectors about documentation practices. While both acknowledged that altercations are handled through risk management, their understanding of medical record requirements differed.
The licensed practical nurse on duty during the incident said notifications to family and physicians would typically be documented in progress notes, but no such notes appeared in either resident's file. The director of nursing suggested a registered nurse may have made notifications for the confused resident, but could not confirm where such notifications were documented.
This documentation failure occurred despite the facility having clear policies requiring incident documentation regardless of whether abuse is confirmed, alleged, or suspected. The policy appears designed to ensure comprehensive record keeping, but was not followed in this case.
The October incident highlights broader challenges in managing residents with different cognitive abilities. The confused resident's tendency to enter other residents' rooms and the alert resident's frustration with perceived inaction by staff created conditions that led to physical contact.
Staff witnessed the entire altercation but failed to create the medical record documentation that would help prevent similar incidents or inform future care decisions for both residents involved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Arcola from 2025-11-18 including all violations, facility responses, and corrective action plans.