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.
Pattern of Wandering and Staff Awareness Issues
Investigation revealed this was not an isolated incident. A family member of the injured resident reported that the aggressive resident had been found in the victim's room "at least 6 different times prior to the incident." Staff confirmed the aggressive resident was known to wander into all other residents' rooms on the unit, take belongings, and even attempt to get into other residents' beds.
Multiple staff members interviewed during the inspection confirmed they were aware of the resident's violent tendencies. One CNA reported that just days before the fatal incident, the aggressive resident had attempted to backhand her when redirected from getting into another resident's bed. When this was reported to the Director of Nursing, the CNA stated she was told "if an incident was resident to staff, the staff were on their own."
The physical layout of the memory care unit compounded these supervision challenges. The aggressive resident's room was located at the end of a hallway near exit doors, with the victim's room directly next door. Both rooms were four doors away from the nurse's station, creating significant blind spots in supervision. The medication aide's practice of charting from a couch in an alcove rather than maintaining visual oversight of the hallway further compromised resident safety.
Medical Implications of Supervision Failures
Subdural hematomas, like the one sustained by the victim, involve bleeding between the brain and its outermost covering. When accompanied by midline shift - a displacement of brain structures from their normal position - this represents a medical emergency requiring immediate intervention. These injuries typically result from significant head trauma and can lead to increased intracranial pressure, altered consciousness, and death if not promptly treated.
The non-displaced clavicle fracture indicated the victim experienced significant force during the altercation. For elderly residents, such fractures can severely impact mobility and independence, increasing risks of pneumonia, blood clots, and other complications during recovery. The multiple skin tears documented on both shins and forearms suggest either defensive wounds or injuries sustained during a fall, both indicating a violent encounter rather than an accidental fall.
Additional Issues Identified
The inspection also revealed serious documentation failures. The facility could not provide behavior monitoring records for the dates immediately following the incident when the aggressive resident was supposedly placed on 15-minute checks. Handwritten copies were only produced after the survey exit. The facility also lacked a behavior management policy, which should outline specific protocols for managing residents with aggressive behaviors.
The admission assessment completed on May 7, 2025, failed to document any behavioral concerns despite multiple staff reports of aggressive incidents in the preceding days. The assessment indicated the resident had "no signs or symptoms of delirium, behaviors, or rejection of care," directly contradicting numerous staff observations and incident reports.
Staff training and communication systems also proved inadequate. Despite the resident being supposedly placed on 15-minute monitoring after the first day, multiple staff members stated they were unaware of this requirement. The facility's position, expressed during the exit conference, that all memory care residents had the "right to wander where they wanted, any time they wanted" including into other residents' rooms at night, demonstrates a fundamental misunderstanding of the facility's duty to protect vulnerable residents from foreseeable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Terre Haute from 2025-05-09 including all violations, facility responses, and corrective action plans.
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