F0600

D

Failure to Prevent Repeated Resident-to-Resident Physical Abuse Despite Known Behavioral Risks

Siler City, North Carolina Survey Completed on 03-13-2026

Penalty

Fine: $19,920

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations involving one resident with dementia and behavioral symptoms. This resident had diagnoses including dementia, psychotic and mood disturbances, and anxiety, and was assessed as severely cognitively impaired with no physical limitations. His care plan, revised multiple times, documented a history and risk of physical behaviors toward others, including prior resident-to-resident incidents. Despite this, his MDS assessments did not reflect behaviors directed toward others during the lookback periods, and the care plan interventions relied on staff recognizing triggers, observing for non-verbal signs of aggression, and removing or diverting the resident as needed.

On one occasion, an altercation occurred between this resident and another cognitively impaired resident with dementia and depressive disorder. The second resident’s care plan documented physical behaviors such as grabbing, pushing, and aggression, as well as verbal behaviors including threatening, cursing, agitation, and delusions. Staff accounts and the facility’s investigation showed that the first resident reported finding the second resident in his room going through his belongings, after which an unwitnessed altercation occurred in the room. Shortly afterward, in front of the nursing station, staff observed the first resident, visibly upset and speaking in broken English, approach the second resident and strike him in the face with an open hand. Staff present at the nursing station were unable to separate the residents quickly enough to prevent the slap.

In a separate incident, the same resident with dementia shared a room with another resident who was cognitively intact but had psychiatric diagnoses including schizoaffective disorder, major depressive disorder, bipolar disorder, PTSD, and a history of hallucinations. This roommate’s care plan noted fluctuating mood, agitation, and anxiety, with interventions focused on redirection and observation for worsening psychiatric symptoms. Staff reported that the two roommates had argued over television volume earlier in the day, with a nursing assistant notifying a nurse about the dispute. Later, a nurse responding to the resident with dementia observed the shared room in disarray and found the cognitively intact roommate with blood on his forehead. The injured resident stated he had been struck on the head with a reaching device by his roommate, and continued to complain about the television volume. The actual assault was not witnessed by staff.

Another incident involved the same aggressive resident and a severely cognitively impaired resident with vascular dementia, insomnia, and anxiety, who was known to wander, enter other residents’ rooms, and show poor awareness of personal space. This resident’s care plan included interventions such as gently guiding him from environments and diverting him with alternative activities. On the date of the incident, the aggressive resident was under 1:1 supervision near the nursing station. Witnesses, including a nurse and the nursing assistant assigned to 1:1, reported that the wandering resident approached and leaned in close to the supervised resident while speaking. Within seconds, the supervised resident stood or reached up and struck the approaching resident across the face with an open hand. The nursing assistant providing 1:1 supervision stated she was within arm’s reach but did not anticipate an altercation and was unable to intervene in time.

Interviews with nursing assistants assigned to provide 1:1 supervision revealed they were not informed of the specific reasons for the supervision or of the resident’s known triggers for aggression, such as others touching his belongings or entering his personal space. One assistant reported only being told to notify a nurse if the resident became upset, and another stated she had not received instructions about triggers or what to avoid. The DON acknowledged being unaware whether NAs assigned to 1:1 supervision were educated about the resident’s triggers, while the ADON stated that staff were supposed to be told triggers but could not recall any formal in-service specific to this resident’s aggression. These gaps in communication and implementation of individualized interventions contributed to repeated resident-to-resident physical abuse incidents involving the same resident, including one that occurred while he was on 1:1 supervision.