F0744

J

Failure to Supervise and Care Plan Aggressive Dementia Behaviors Resulting in Resident Injury

Plainfield, Indiana Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and appropriate interventions for a resident with severe vascular dementia and a history of aggressive behavior, resulting in physical harm to another resident. The aggressive resident was a tall, muscular man with diagnoses including severe vascular dementia with behavioral disturbance, anxiety disorder, history of alcohol dependence, and major depressive disorder. His care plans, initiated earlier in the year, identified behaviors such as hiding or refusing medications, verbal aggression, exit-seeking, refusal of showers, moving furniture, and making threats like “I’m going to hit you.” Interventions listed included monitoring behavioral episodes, determining underlying causes, documenting behaviors, protecting the rights and safety of others, and diverting or removing the resident from situations as needed. Another care plan addressed psychotropic medication use for aggressive behavior, with instructions to monitor and document target behaviors such as pacing, wandering, disrobing, inappropriate responses, and violence or aggression toward staff and others.

Despite these documented behavioral issues and the resident’s known background as an Olympic boxer, the facility did not update his care plans or add specific interventions after multiple serious incidents of physical aggression and wandering. On one occasion, the resident attempted to enter another resident’s room while a visitor was present; when staff tried to redirect him, he balled his fist, hit a CNA in the face, threatened to “get them all,” and attempted to hit another CNA who approached him. On another occasion, he believed a female resident’s wheelchair was his car, grabbed the handles, pulled the wheelchair back at an angle, and caused her to fall to the floor, resulting in bruising and swelling to her right eye and nose after her eyeglasses hit the floor. Staff and behavior monitoring sheets documented repeated episodes of agitation, wandering into other residents’ rooms, and combativeness over multiple days, yet the resident’s record lacked care plans or interventions specifically addressing his physical aggression toward staff and residents or his wandering into others’ rooms.

Additional events further demonstrated the resident’s ongoing aggressive and intrusive behaviors without corresponding care plan updates. A nurse practitioner documented that the resident was at high risk to himself and others, noting intermittent aggressive behaviors, resistance to care, and frequent medication refusals. The resident was found lying in a bed in a female resident’s room while she was in her own bed, and he became combative when staff attempted to remove him, requiring assistance from additional male CNAs to get him out of the room. Staff interviews indicated that the resident could be unpredictable and violent, had previously hit a CNA in the face, assumed a fighting stance when agitated, and that residents stayed away from him. A family member of another memory care resident reported being afraid of him and requesting an escort off the unit after visits. Observations showed the resident attempting to take other residents’ equipment and exit doors, with staff using ad hoc redirection. The facility’s documentation lacked behavior monitoring prior to the 15-minute monitoring period and did not reflect the incidents of 12/12, 12/30, or 1/13 in the care plan, resulting in a failure to implement and document appropriate, individualized interventions and supervision for an aggressive dementia resident.

The cumulative effect of these actions and inactions—failure to update care plans after significant aggressive incidents, lack of documented targeted interventions for physical aggression and wandering, and reliance on informal staff redirection despite known risks—led to the deficiency cited by surveyors. The aggressive resident’s behaviors, including striking staff, forcibly removing another resident from a wheelchair causing injury, entering other residents’ rooms, and resisting redirection, were repeatedly observed and reported, yet the facility did not revise the resident’s care planning to address these escalating behaviors as required.