Signature Healthcare Terre Haute: Dementia Attack IN

TERRE HAUTE, IN - A state inspection revealed that Signature Healthcare of Terre Haute failed to implement proper supervision and interventions for a dementia resident with documented aggressive behaviors, resulting in another resident sustaining a fractured clavicle, subdural hematoma, and multiple skin tears during an unsupervised encounter in May 2025.

Failure to Supervise Resident with History of Violence

The facility admitted a resident with early-onset Alzheimer's disease on May 2, 2025, despite documentation showing the individual had physically assaulted two other residents at a previous nursing home within the four months prior to admission. The most recent documented assault had occurred just weeks before the transfer.

Within hours of admission, staff documented that the new resident displayed exit-seeking behaviors, verbal aggression toward staff including cursing and spitting, and attempted to throw objects at caregivers. Most concerning, staff noted the resident "targeted resident rooms with stop signs on them and ripped the signs down," creating immediate safety concerns for other vulnerable residents on the memory care unit.

Despite these documented behaviors and the resident's known history of physical altercations, the facility failed to implement adequate supervision protocols. While administration was notified and staff were instructed to maintain 15-minute checks and have "eyes on" the resident to prevent entry into other residents' rooms, inspection findings revealed these interventions were not consistently implemented or documented.

Critical Incident Results in Life-Threatening Injuries

On the night of May 9, 2025, the lack of proper supervision led to devastating consequences. Two certified nursing assistants were providing care to another resident at the end of the hallway, while the medication aide sat charting on a couch in an alcove where she "did not have a view" of the residents' rooms. The aggressive resident was left unsupervised for what staff estimated was between one and three minutes.

During this brief lapse in supervision, the resident with aggressive behaviors entered another resident's room. Staff only became aware of the situation when they heard the victim say "ouch" loud enough to be heard from approximately 100 feet away at the nurse's station. The aggressive resident was then observed exiting the victim's room with three circular bruises on the right lower arm and fresh scratches with blood on them.

The victim was discovered sitting on the floor near the bathroom doorway with severe injuries including skin tears on both lower shins, scratches and skin tears on the right forearm, and complaints of right shoulder pain. Emergency services transported the victim to the hospital, where medical evaluation revealed a non-displaced acute distal right clavicle fracture and a subdural hematoma with mild midline shift. The victim died several days later on May 13, 2025.

Inadequate Care Planning Despite Known Risks

The facility's failure to develop and implement an appropriate care plan for the aggressive resident represents a fundamental breakdown in dementia care protocols. Despite the resident's documented history of physical altercations and the immediate behavioral issues observed upon admission, the care plans dated May 3 and May 4, 2025, contained only generic interventions such as "encourage the resident to participate in activities" and "observe the resident's wandering patterns."

The care plans critically failed to address the resident's history of violence, physical aggression toward staff, or the specific behaviors witnessed on the first day including exit-seeking, throwing objects, and verbal aggression. No physician's order for behavioral monitoring was documented until May 10, 2025 - after the fatal incident had already occurred.

Standard dementia care protocols require comprehensive behavioral assessments and individualized intervention strategies for residents with histories of aggression. These should include specific de-escalation techniques, identification of triggers, structured daily routines to minimize agitation, and clear protocols for when one-to-one supervision is required. The facility's generic approaches failed to meet these basic standards of care.