F0744

G

Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations

Bowerston, Ohio Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services, including non‑pharmacological interventions, for residents with dementia and behavioral disturbances, which resulted in resident‑to‑resident altercations and actual harm. Two residents with dementia and significant behavioral histories repeatedly wandered, entered other residents’ rooms, and displayed agitation and aggression without evidence of effective monitoring or individualized non‑pharmacological strategies to manage these behaviors or prevent altercations. The facility relied heavily on psychotropic medication adjustments and brief periods of increased supervision, without documenting or care‑planning specific behavioral interventions tailored to each resident’s needs.

One resident had vascular dementia with behavioral disturbance, agitation, anxiety, sundowning, combative behavior at night, and a history of throwing a chair, walking naked, and visual hallucinations. Orders included multiple psychotropic medications such as Haldol, Ativan, Vistaril, Depakote, Trazodone, and later Klonopin, with several dose changes over time. Nursing notes repeatedly documented this resident wandering the halls, entering other residents’ rooms, pacing, yelling, slamming chairs and doors, being verbally and physically aggressive, and having explosive episodes. The care plan identified mood and behavior problems, including disruptive behavior, resisting care, socially inappropriate behavior, wandering into other rooms, exit seeking, and combativeness, but listed only general interventions such as consulting social services, administering medications, monitoring behaviors, and gentle redirection. There was no documented evidence of specific non‑pharmacological interventions being planned or implemented to address these behaviors.

The second resident had diagnoses including behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, delirium, and later severely impaired cognition, with documented behaviors such as wandering daily, rejecting care, and physical and verbal behaviors toward others. This resident frequently wandered into other residents’ rooms and was found in their recliners or beds, yet the record showed no non‑pharmacological interventions to address wandering or to prevent altercations. Multiple incidents occurred between the two residents: one resident hit the other on the jaw while the victim sat near the nurse’s station; on another occasion, one resident repeatedly rammed a walker into the other’s legs, leading to mutual hitting and facial scratches; and later, the wandering resident entered the other’s room, resulting in a serious altercation where the victim was found on the floor with significant facial trauma, periorbital swelling, scalp laceration, and a large bruise from hip to knee. Despite these escalating events and the known mutual dislike between the two residents, interviews and record review confirmed that no new, individualized non‑pharmacological interventions were added beyond temporary increased or one‑on‑one supervision, and the facility did not effectively implement behavioral health services to prevent further resident‑to‑resident altercations.

Title: Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations

ShortSummary: Two residents with dementia and significant behavioral histories repeatedly wandered, entered other rooms, and displayed agitation and aggression without individualized non‑pharmacological interventions or effective behavioral health care plans. Staff documented frequent wandering, pacing, yelling, slamming furniture, and explosive episodes, and the care plans relied largely on psychotropic medications and general redirection rather than specific, person‑centered strategies. Multiple altercations occurred, including one resident striking another near the nurse’s station, an incident involving a walker being rammed into another resident’s legs with mutual hitting and facial scratches, and a later episode in which a wandering resident entered another’s room and sustained significant facial trauma, scalp laceration, and extensive bruising. Records and interviews confirmed that, despite these events and awareness that the two residents did not get along, the facility did not develop or implement comprehensive, individualized non‑pharmacological interventions to manage behaviors or prevent further resident‑to‑resident altercations.