F0600

G

Failure to Prevent Repeated Resident-to-Resident Abuse by a Behaviorally Symptomatic Resident

Irving, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from abuse by another resident with known behavioral symptoms. Resident #1, an elderly female with dementia, generalized anxiety disorder, and severe cognitive impairment (BIMS score of 0), had an active care plan identifying behavioral symptoms including verbal and physical aggression and calling 911. Her care plan included various behavioral interventions such as removal from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, avoiding power struggles, avoiding overstimulation, and assessing whether her behavior endangered herself or others. Despite these identified behavioral issues and interventions, Resident #1 engaged in multiple aggressive acts toward other residents.

On 03/01/26, Resident #1 was involved in an incident with Resident #2, an elderly female with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and a care plan that identified behavioral symptoms including physical aggression and sexually inappropriate behaviors. According to a progress note by RN A, a CNA/Medication Aide reported that Resident #2 was walking in front of Resident #1 in the dining room when Resident #1 suddenly stood up, ran toward Resident #2, and pulled her hair. RN A heard Resident #2 screaming loudly and believed the scream sounded like it was due to pain from having her hair pulled. Staff separated the residents, and a head-to-toe assessment revealed no injuries, bruises, or need for treatment, but the event constituted resident-to-resident physical aggression.

On 03/05/26, Resident #1 engaged in another aggressive incident, this time with Resident #3, an elderly female with dementia, bipolar disorder, generalized anxiety disorder, severe cognitive impairment (BIMS score of 0), and a history of aggression noted in her care plan. LVN B reported observing Resident #1 yelling at Resident #3 and, before she could reach them, witnessing Resident #1 scratch Resident #3’s face with her fingernails. Resident #3 was noted to have red marks on her face without skin break, and she was angry and agitated for about forty minutes following the incident. On 03/10/26, Resident #1 again acted aggressively toward Resident #4, an elderly female with Alzheimer’s disease, epilepsy, mood disorder, and an admission MDS showing no mood or behavioral symptoms. LVN B reported that Resident #1, without provocation, grabbed Resident #4 by the throat, pulled her hair, and verbally threatened her, telling her to stop looking at her and threatening to cut her throat. Resident #4’s breathing was not restricted and no injuries were observed, but the incident involved physical and verbal aggression. These repeated episodes of resident-to-resident abuse occurred despite Resident #1’s known behavioral history and existing care plan, and the DON acknowledged that failing to update interventions in Resident #1’s care plan after such acute incidents would be a risk because the care plan is the means to communicate necessary interventions to all caregivers.

The facility’s own policy titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” stated that residents have the right to be free from abuse and included an objective to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including other residents. Nevertheless, Resident #1 was able to pull Resident #2’s hair, scratch Resident #3’s face, and grab Resident #4 by the throat and pull her hair while verbally threatening her. Staff interviews confirmed that these events occurred and that Resident #1’s behavior was described as random and unpredictable. The DON stated she had not been aware of at least one of the aggressive incidents at the time of interview and indicated that the comprehensive care plan is supposed to be updated for acute incidents. The combination of Resident #1’s known aggressive behaviors, the occurrence of multiple aggressive episodes toward other residents, and the lack of timely, effective care plan updates and interventions to prevent further abuse formed the basis of the deficiency under the facility’s obligation to protect residents from abuse by anyone, including other residents.