McCormick Post Acute: Resident Attacked Three Times - SC

The March 9 incident at McCormick Post Acute involved two residents with severe cognitive impairment. Federal inspectors found that after each attack, staff simply separated the residents but took no meaningful steps to prevent the violence from recurring.

Licensed Practical Nurse LPN1 witnessed all three attacks. She told investigators that Resident 103 came around the nurse's station and attacked Resident 83, who was sitting in her wheelchair in the hallway. LPN1 observed Resident 103 "hitting R83 on the arm and maybe on the chest with a closed fist."

She separated them and took Resident 103 to her room, leaving Resident 83 in the hallway.

Minutes later, the violence resumed. LPN1 heard hollering again and found that Resident 103 had returned and was "hitting R83 on her arms/chest again in the hall." She took Resident 103 back to her room a second time and moved Resident 83 to the parlor by the nurse's station.

The attacks continued. A few minutes later, LPN1 heard hollering for a third time and "found R103 hitting R83 again in the parlor." Only then did she take Resident 83 to another unit entirely.

"R103 attacked R83 three different times in about a 45-minute period," LPN1 told inspectors.

The nurse said Resident 103 "understood what she was doing" and that her "behaviors went from 0 to 100 in seconds." Staff had tried to watch her when she came out of her room, but LPN1 acknowledged that "staff were not doing enough to keep her or other residents safe."

Assessment records showed both residents had severe cognitive impairment. Resident 103 scored zero out of 15 on a mental status evaluation, while Resident 83 scored 5 out of 15.

The facility's Director of Nursing told inspectors he was unaware that Resident 103 had been allowed to attack Resident 83 three separate times. He said staff had told him "it was not that serious" and that he thought "R103 hit R83 once and they were separated and there were no further issues."

Two nursing assistants assigned to the residents that day said they didn't witness the incident and were unaware that Resident 103 required increased supervision.

The violence wasn't limited to that March incident.

On April 14, Resident 103 attacked another patient during a smoking break in the facility's courtyard. According to the Director of Nursing's notes, Resident 103 became frustrated when she couldn't get past other residents near the door. She "pulled one resident's wheelchair backwards causing it to strike [Resident 6's] legs."

When Resident 6 expressed displeasure with being hit, Resident 103 responded by saying "F**k you," then "slapped [R6] on the knee and spit on her smoking apron."

Resident 6 remembered the incident when inspectors interviewed her. She said the wheelchair strike didn't cause injury, but after they exchanged words, Resident 103 "started spitting on her apron then came closer and closer and hitting her knee." Resident 6 said her knee was sore for a few days.

A nursing assistant who witnessed the April incident provided a more detailed account. She said Resident 103 moved another resident's wheelchair into Resident 6's stump, leading to an exchange of profanities. After Resident 103 spit on Resident 6, the Director of Nursing came outside and took Resident 103 inside to calm the situation.

But according to the nursing assistant, Resident 103 "came back out and swung around" the Director of Nursing and "hit [R6] on the leg." The Director of Nursing denied that Resident 103 returned to the courtyard, creating conflicting accounts of what happened.

Federal inspectors found that the facility failed to conduct thorough investigations of either incident. After the March attacks, there was no documentation of a skin assessment for Resident 83, despite facility policy requiring such examinations. Investigators found no evidence that the facility interviewed LPN1, who witnessed all three attacks, or the nursing assistant assigned to Resident 103, or any other residents who might have seen what happened.

The Director of Nursing acknowledged these failures, telling inspectors he should have interviewed other staff, obtained written statements, and documented Resident 83's skin assessment. The Operations Manager, who served as the facility's abuse coordinator, agreed that "there should have been more interviews conducted."

The facility did arrange psychiatric consultations for Resident 103 on March 10 and April 15, and medications were adjusted. The Social Service Director sent a referral for behavioral placement evaluation on April 15, but inspectors found no follow-up documentation about the status of that referral.

After inspectors arrived, the facility developed what it called an "acceptable removal plan." Resident 103 was placed on one-to-one observation, and her care plan was updated. The facility conducted interviews with residents who had sufficient cognitive ability and provided education to all staff about abuse reporting and resident separation.

The facility identified the root cause as "lack of accurately reporting events and behaviors to Admin staff and failure to ensure residents kept separated once an alteration occurred."

Both residents involved in the March incident had severe cognitive impairment that would have made them particularly vulnerable. Resident 103's assessment showed the most severe level of cognitive decline possible, while Resident 83's condition was nearly as impaired.

LPN1's stark assessment captured the facility's fundamental failure: if they moved Resident 103 to another unit, "she will just do the same thing there." The nurse said she didn't know what staff could do to keep residents safe, a confession that highlighted how unprepared the facility was to handle residents with severe behavioral issues.

The repeated attacks occurred despite the facility's policy defining abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." The policy specifically stated that abuse "includes verbal abuse and mental abuse" and applies to "all residents, irrespective of any mental physical condition."

Federal inspectors classified the violations as immediate jeopardy to resident health and safety, the most serious level of harm in nursing home enforcement. The facility was required to implement immediate corrective actions to remove the jeopardy before inspectors would close their investigation.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mccormick Post Acute from 2025-05-02 including all violations, facility responses, and corrective action plans.

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