F0600

G

Failure to Protect Residents From Repeated Physical Abuse by an Aggressive Resident

Concord, North Carolina Survey Completed on 02-27-2026

Penalty

Fine: $44,925

Summary

The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing a cognitively intact resident with a known history of aggression toward others. This resident had diagnoses including anxiety, violent behavior, bipolar disorder, paranoid schizophrenia, dementia with mood disturbance, and insomnia, and was receiving antipsychotic, antianxiety, and antidepressant medications. His care plan documented a history of verbal aggression, poor impulse control, and threatening statements toward peers, with interventions such as 1:1 activity as needed, monitoring behavior episodes, explaining procedures, allowing time to adjust to changes, and psychiatric/behavioral services as needed. Despite this known history and care plan, the resident repeatedly engaged in physical aggression toward other residents.

In the first incident, a severely cognitively impaired resident who was fully dependent for ADLs (except eating) and used a manual wheelchair entered the aggressive resident’s room. Staff did not witness the event, but the roommate called out for help, and staff found the cognitively impaired resident outside the doorway with a bruised, swollen, cut upper lip that had been bleeding. Nursing staff and the on‑call provider documented that the injuries were consistent with being struck in the mouth with a closed fist, and the aggressive resident told a nurse he hit the other resident because he did not want her in his room. The facility was aware of the aggressive resident’s past aggressive behaviors toward residents and staff prior to this event.

In a subsequent incident involving the same two residents, the aggressive resident again spat on, cursed at, and punched the severely cognitively impaired resident when she wandered into his room. The cognitively impaired resident sustained swelling and bleeding of the lip and jaw, swelling and bruising of the upper lip, and swelling of the right eyebrow, and she was unable to reliably communicate pain. Documentation noted that she had been assaulted by the same resident two months earlier. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after activating his call light to request a lower room temperature, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body. The new resident reported feeling victimized, unsafe, and as though he had to sleep with one eye open. The aggressive resident told staff he spit on and punched this roommate because he believed he was going to be kicked. The Psychiatric NP and Medical Director both stated that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or altered his environment, and that he would likely respond the same way again if not redirected by staff.