Woodland Terrace: Staff Tapped Dementia Patient's Head - IA

Staff C worked multiple hallways during her shift but managers considered the incident "isolated" without investigating further. The facility's director of nursing acknowledged that none of the residents in the dementia unit have the cognitive ability to report if something happened to them.

"None of the residents have a high enough BIMS score for that," Staff A told inspectors, referring to the mental status screening used to assess cognitive function in nursing homes.

The incident came to light during a complaint investigation in August. Staff C eventually admitted she had tapped Resident #1 on the head, but the facility's response raised questions about how thoroughly they protect vulnerable patients.

Staff A, who worked that morning shift, told inspectors she never conducted physical head-to-toe assessments on any other residents after the incident with Resident #1. She explained that while staff are assigned to specific wings, they routinely help in other areas when call lights go off or residents need assistance.

"Staff verbally designate a certain wing for each CNA in the unit when they come on shift for rounds, but if there is a call light or a need the aide may work other hallways/rooms," Staff A said.

Staff C had worked the A hallway that night but could have provided care to residents throughout the facility.

When inspectors interviewed Staff J, the director of nursing, on August 26, she revealed significant gaps in the facility's investigation. Staff J said she and another director of nursing had interviewed Staff A and other staff after the incident, but when asked why the facility's investigation file contained no documentation of these interviews, she offered an troubling explanation.

"They had done a lot of investigations lately, so maybe they didn't talk to the staff," Staff J said. "If they would have talked to other staff, then it would have been documented in the investigation."

Staff J confirmed that no other residents were assessed after the incident with Resident #1. She reviewed the dementia unit's resident roster and considered whether any patients might be able to remember if they had been mistreated.

"Possibly Resident #6 may be able to remember, but that would be giving a lot of the benefit of the doubt," Staff J said. After further consideration, she concluded there weren't really any residents who would be able to recall if something had been done to them.

The nursing directors felt confident they were dealing with an isolated incident. They never conducted resident interviews in other areas where Staff C had worked to determine if other patients had been affected.

Staff B, another director of nursing interviewed the same day, confirmed that no other residents in the unit were assessed after Resident #1's incident. When asked if any residents could report mistreatment, she reviewed the dementia unit's resident list and responded, "probably not."

Like her colleague, Staff B acknowledged they had not interviewed residents in other areas where Staff C had provided care.

The investigation process itself appeared haphazard. During a follow-up interview on August 27, Staff J explained that when suspected abuse occurs, she expects nurses to assess the involved resident, complete an incident report, and notify the physician and family.

But the facility lacks basic investigative tools.

"When they do investigations, they just do them off the top of their head," Staff J said. "They do not have any investigation checklist or tools to use. It would be nice to be able to ensure they are covering everything and that all departments are doing what they need to do for an investigation."

The administrator, interviewed the same day, acknowledged the investigation's shortcomings. She said the directors of nursing handle investigations and "it gets to be a lot so they have one person take lead on the investigation."

She considered the investigation for Resident #1 closed at the time of the inspection.

"She would have expected the nurse to look at other residents," the administrator admitted. "In hindsight, it would have been good to go back and look at the residents that Staff C had contact with, especially residents that required one assist as Staff would have been the only resident in the room with them."

The administrator explained why the investigation was limited: "The investigation was lacking because Staff C admitted what happened and the DON's thought it was an isolated situation."

The facility is now reviewing its procedures. "They are reviewing and will be making changes going forward," the administrator said.

Woodland Terrace's own policies require more thorough investigations. The facility's Dependent Adult Abuse Prevention Policy, revised in November 2023, defines abuse as "the willful inflection of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish."

The policy specifies that "willful" means an individual must have acted deliberately, regardless of whether they intended to cause injury or harm. Under the procedure section, the policy directs that "a thorough investigation would be implemented."

The inspection revealed a troubling gap between policy and practice. While Staff C admitted to inappropriate contact with one dementia patient, the facility's investigation failed to determine whether other vulnerable residents experienced similar treatment that night.

The administrator's acknowledgment that residents requiring one-person assistance would have been alone in their rooms with Staff C highlighted the missed opportunity to protect some of the facility's most vulnerable patients.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Woodland Terrace from 2025-08-27 including all violations, facility responses, and corrective action plans.

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