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F0600
J

Failure to Protect Residents from Abuse and Neglect Due to Inadequate Supervision of Aggressive Resident

Mccomb, Mississippi Survey Completed on 10-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from abuse, neglect, and intimidation by admitting and retaining a resident with known aggressive and violent behaviors without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The resident in question had diagnoses including Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and was assessed as having severe cognitive impairment. Despite repeated incidents of aggression, threats, and physical intimidation towards both staff and other residents, the facility did not provide necessary psychiatric intervention or relocate vulnerable roommates to ensure their safety. Multiple residents were directly affected by the aggressive behaviors. One resident, who shared an adjoining room, reported being repeatedly threatened and verbally abused at night, leading to fear and inability to sleep. Another roommate experienced threats and was once barricaded in the room by the aggressive resident, preventing access to medication and staff intervention. A third resident, located across the hall, expressed fear and avoided leaving her room when the aggressive resident was present and yelling in the halls. Staff interviews confirmed that these behaviors were ongoing and that no formal interventions, such as increased supervision or room changes, were implemented to protect the affected residents. Progress notes and staff interviews documented a pattern of escalating behaviors, including refusal of medication, threats to kill staff and residents, inappropriate sexual comments, physical aggression, and property damage. The aggressive resident repeatedly barricaded doors, threatened others, and required police and emergency medical intervention on multiple occasions. Despite these incidents, the facility did not implement effective interventions or provide adequate supervision, resulting in an unsafe environment and placing multiple residents at risk for serious injury, harm, impairment, or death.

Removal Plan

  • Resident #1 was transported to the local emergency department and subsequently to an inpatient behavioral health facility; Resident #1 remains in inpatient behavioral health facility.
  • Once Resident #1 exited the facility, the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
  • The Executive Director interviewed the resident that was barricaded in the room with Resident #1 to assess for fear or trauma.
  • The facility issued an emergency notification of discharge to Resident #1's family and began searching for alternative placement; Resident #1 will not return until cleared and appropriate safeguards are in place.
  • Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy, with emphasis on resident psychosocial harm, de-escalation of behavioral episodes, and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
  • Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of residents.
  • Interviews with current residents with a BIMS of 10 or greater were conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or incident of trauma.
  • Residents #2, #3, and #4's care plans were updated to include trauma-centered care.
  • The Quality Assurance Performance Improvement (QAPI) Committee met to review the incident and policies.
  • Abuse Neglect Policy, Behavioral Health Policy, and Accidents and Supervision Policy were reviewed.
  • The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm, abuse de-escalation of behavioral episodes, and investigation of psychosocial harm.
  • Affected residents' care plans were updated to reflect trauma-informed care by the Care Plan team.
  • The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations, and Accidents and Hazards.
  • An Emergency Quality Assurance Committee was held with key facility staff in attendance.
See complete original report
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