F0600

D

Failure to Protect Cognitively Impaired Residents From Peer-to-Peer Physical Abuse

Whitesboro, Texas Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from abuse by other residents, specifically when one cognitively impaired male resident in the memory care unit physically struck another cognitively impaired male resident. The resident who was hit had Alzheimer’s disease and unspecified psychosis, with severely impaired cognition (BIMS score of 05), wandered daily, and required assistance with self-care and mobility. His comprehensive care plan addressed impaired cognition and dementia but did not include any behaviors toward staff or other residents. At the time of the incident, he was sitting on a couch in the dining room watching television and wearing a cowboy hat when another resident approached him.

The resident who initiated the physical contact had dementia, schizophrenia, and bipolar disorder, with severely impaired cognition (BIMS score of 00) and a care plan that identified potential for physical behaviors. His care plan interventions included medication review and minimizing disruptive behaviors by offering diversionary tasks. Prior to the incident, nursing notes documented that this resident had been agitated with staff and had swung at a staff member and another resident on separate occasions, requiring redirection to his room and environmental modifications to decrease stimulation. CNAs reported being warned to watch this resident because he might try to hit staff, and one CNA described that he had swung at her when she attempted to seat him in a chair without arms, noting that his response depended heavily on how he was approached.

On the day of the incident, a CNA observed the resident with a history of physical behaviors walk to the sofa where the other resident was sitting and hit him on the right side of his head while he was wearing his cowboy hat. The CNA also reported that the aggressor began kicking his foot toward the seated resident, although his foot did not make contact. Another account from facility leadership described the action as the aggressor walking over and tapping the seated resident on his cowboy hat. The LVN on duty documented that he was informed that the seated resident was on the couch and the other resident hit him, and he noted that no injury was observed. Interviews after the event showed that both residents denied remembering the incident, and the resident who was struck denied being hit when asked. Despite prior documentation of the aggressor’s physical behaviors and staff awareness that he might attempt to hit, the facility did not prevent the incident in which one resident physically struck another, resulting in a failure to protect residents from abuse as defined in the facility’s abuse/neglect policy, which includes hitting and kicking as physical abuse.