F0744

D

Failure to Implement Person-Centered Care Plan for Dementia-Related Targeted Verbal Abuse

Fayetteville, North Carolina Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement individualized, person-centered care plan approaches for a resident with dementia who exhibited a known pattern of targeted verbal behaviors toward another resident. Resident #8 was admitted with early onset Alzheimer’s disease, dementia, major depressive disorder, and a history of stroke, and was assessed as moderately cognitively impaired. His care plan was updated to include a problem of frequent conflicts with peers and staff, including cursing and yelling at his roommate and unprovoked expressions of anger, with general interventions such as staff intervening when inappropriate behaviors were observed, reminding him to communicate anger without being verbally aggressive, and referring him to psychiatry. Despite these care plan approaches, the facility did not create specific interventions addressing his ongoing, targeted derogatory name-calling toward Resident #9.

Over time, staff and residents reported that Resident #8 repeatedly directed slurs and sexually explicit, derogatory language at Resident #9, often in common areas and from the hallway outside Resident #9’s room. On one documented occasion, a nurse noted that a nurse aide overheard Resident #8 cursing and yelling at another resident and redirected him away from that resident’s doorway; the targeted resident reported that the incident was unprovoked and that this type of behavior had occurred previously. In interviews, Resident #9 described that after initially thinking Resident #8 was “cool,” Resident #8 began calling him derogatory names almost daily when they were both outside their rooms, and two to three times a month from the doorway of his room, using terms such as “ole faggot,” “ole bitch,” and sexually explicit threats. Another cognitively intact resident corroborated that he had witnessed Resident #8 calling Resident #9 a “faggot” for no apparent reason.

Multiple staff interviews confirmed that these behaviors were recurrent and directed specifically at Resident #9. Nurse aides and nursing staff reported that Resident #8 frequently called Resident #9 a “faggot” and threatened to beat him, that such incidents occurred multiple times per week in the dining/activity room, and that redirection was difficult because Resident #8 became angry when redirected. Staff also reported that Resident #8 had previously directed derogatory remarks at another resident but had shifted his focus to Resident #9. The social worker acknowledged that Resident #9 had reported being stared at and subjected to negative and sexual remarks by Resident #8 and that nurse aides were supposed to redirect Resident #8 and keep the residents separated, but she did not document these reports. The care plan nurse stated that the care plan had not been revised to specifically address Resident #8’s targeted verbal behaviors toward Resident #9, and the active care plan contained no problem or interventions related to this known pattern of derogatory name-calling. The psychiatric NP and medical director were not fully informed of the frequency and targeted nature of the behaviors, and the administrator confirmed there was no documentation that Resident #9 had provoked Resident #8. As a result, the facility continued to rely on ineffective, generalized behavior interventions and failed to implement individualized strategies to manage Resident #8’s dementia-related verbal behaviors toward Resident #9.

The facility’s documentation and communication practices contributed to the deficiency. Nursing and social service notes for the months surrounding the incidents contained minimal entries about Resident #8’s behaviors toward Resident #9, despite multiple staff and resident accounts of frequent episodes. The psychiatric NP noted only one documented incident in the record and was not made aware that the derogatory language was occurring more often than charted or that it was specifically targeted at Resident #9. The social worker did not create written notes to track the timing and frequency of Resident #9’s complaints, and the DON was not aware of the specific details of the targeted verbal abuse. Although staff reported that one-on-one supervision had been used for Resident #8 in the past, there was no clear documentation of why it was initiated or discontinued, and no corresponding care plan revisions were made to address the ongoing pattern of verbal aggression toward Resident #9.