Failure to Protect Resident from Verbal and Mental Abuse
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member. The incident involved a moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome, who was observed to become visibly tense and tearful when a CNA entered her room. The CNA rushed through care and became argumentative with a rude, aggressive tone when the resident requested to have her teeth brushed. This interaction left the resident feeling worthless and tearful, as she reported that the CNA and other staff members often spoke to her with harsh tones and exhibited negative attitudes and body language towards her. The resident's clinical record revealed she required significant assistance for transfers and activities of daily living due to her condition. During an interview, the resident stated that the CNA was rough when assisting her with care and would respond rudely when asked to be gentler. The resident expressed that the CNA's tone, body language, and facial expressions made her feel judged and like a burden. She also reported that the CNA would rush through her care and not meet all her needs, leaving her feeling ignored and with a negative attitude. The resident's roommate corroborated these observations, stating that the CNA spoke to the resident in a rude manner and made it clear she did not want to provide the requested assistance. The Director of Nursing and the Administrator both confirmed that staff should handle residents with respect and dignity, and agreed that the resident was not treated appropriately. The report concluded that the facility failed to protect the resident's right to be free from verbal and mental abuse, resulting in psychosocial harm.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
Staff failed to protect a severely cognitively impaired, incontinent resident from physical abuse when an LPN, acting on an order for UA with C&S, attempted in-and-out catheterization after the resident could not void into a urinal. The resident verbally and physically resisted, but the LPN summoned two CNAs who held the resident’s arms and legs while the catheter was inserted. Bright blood was observed in the urine during the procedure, which was then stopped, and later hematuria with clots and pain on urination were documented, leading to transfer to the hospital where the resident returned with an indwelling catheter and blood in the urine. Facility investigation and staff interviews confirmed that the resident was restrained during the procedure and that the incident met the facility’s definition of abuse.
A resident with severe cognitive impairment and multiple comorbidities was subjected to physical and verbal abuse by a CNA during incontinence care. The resident, who had previously shown no resistance to care, became combative when the CNA attempted to clean her. According to an RN’s eyewitness account, the CNA ignored the resident’s request to stop, pushed the resident onto her side while searching for a broken necklace, then punched the resident twice in the back/thigh area and stated she did not care anymore. The resident subsequently ran into the hallway partially unclothed, refused assessment and care, and exhibited agitation and confusion, later telling psychiatry that the CNA had come from behind, grabbed, and started hitting her until staff intervened.
A resident with dementia, psychotic and anxiety disorders, but intact daily decision-making abilities, required extensive assistance with self-care, including bathing. During shower care, a CNA repeatedly called the resident a “witch” and then rolled the resident in front of a fan while transporting her in the corridor, causing the resident to yell from discomfort due to the cold air. Other staff later described the resident as sometimes stating she was cold and being impatient but not aggressive, and an LPN reported that staff are instructed to step away and report behaviors when they occur. Despite prior abuse education for staff, this incident showed that the resident was not protected from verbal and physical abuse.
Multiple residents experienced repeated physical abuse from other residents, primarily on a memory care unit, including being struck in the face, head, shoulder, arm, and mouth, having hair pulled, and being knocked to the floor. These altercations typically occurred in common areas while residents were wandering or seated, often when one resident became agitated about personal space or perceived a need to protect staff. Many involved residents had cognitive impairment and could not recall the events, though staff and other residents sometimes witnessed the incidents and documented assessments showing either no injury or minor findings such as bruising or redness. Despite these documented episodes and staff acknowledgment that such conduct constitutes abuse under the facility’s abuse policy, the comprehensive care plans for the abused residents did not include information about the incidents or individualized approaches to address the abuse or prevent recurrence, resulting in an immediate jeopardy determination.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Resident Restrained for Catheterization Resulting in Bleeding and Hospitalization
Penalty
Summary
Facility staff failed to protect a cognitively impaired resident from physical abuse during an attempt to obtain a urine specimen. The resident had benign prostatic hyperplasia and was documented as severely cognitively impaired on the admission MDS, with a BIMS score of 4/15 and urinary status coded as always incontinent. A physician’s order dated 01/24/2025 directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening of 01/28/2025, an LPN attempted to collect a urine sample. When the resident was unable to void into a urinal, the LPN proceeded with an in-and-out catheterization despite the resident’s cognitive impairment and subsequent resistance. During the catheterization attempt, the resident verbally and physically resisted the procedure. According to the resident’s friend, who was present, the resident stated words such as “Don’t do that” and crossed his legs, and later grabbed his penis to stop the nurse. The LPN then called for assistance from two CNAs. The friend reported being asked to step into the hallway, where she heard the resident yelling but could not make out his words. Staff interviews and written statements confirmed that the CNAs held the resident’s arms and legs while the LPN inserted the catheter in order to obtain the urine specimen. The LPN later acknowledged that the resident was restrained during the procedure and that she believed restraining residents in this manner was common practice, and she expressed surprise when informed that residents have the right to refuse care and cannot be restrained against their will. Bright blood was noted in the urine during the catheterization, at which point the LPN stopped the procedure, removed the catheter, and documented that the resident appeared anxious but stable. Later that night and early the following morning, staff documented that the resident experienced discomfort and pain with urination, with hematuria and blood clots noted in the brief. The on-call NP was notified and ordered transfer to the hospital, where the resident was found to have an indwelling urinary catheter with blood in the urine. Facility investigation, including staff interviews and review of statements, concluded that the CNAs had held the resident’s arms and legs while the LPN catheterized him, and the allegation of abuse was substantiated as willful infliction of injury by forcing a procedure against the resident’s will, resulting in bleeding and hospitalization.
Removal Plan
- The allegation was reported, investigated and substantiated for abuse.
- Staff members involved were placed on paid administrative leave pending investigation and subsequently terminated and reported to their respective licensing agencies.
- Immediate skin assessment completed on the resident; no skin impairment or changes noted.
- The resident was evaluated by the facility social worker for psychosocial distress related to the incident; no distress was reported or observed.
- Residents with orders for straight catheterization were identified as potentially affected.
- Immediate skin checks were completed for all residents.
- Resident interviews were conducted and no care issues or abuse issues were identified.
- Staff members were in-serviced and educated on abuse policies and procedures and who the abuse coordinator is.
- Staff were educated on a resident's right to refuse or decline care and procedures and how nursing staff are to respond when a resident refuses care or treatment.
- Staff were educated to offer alternatives if possible and provide education on the needed treatment.
- Abuse and Neglect Prevention Training will be assigned and monitored for all new hires during orientation and annually for all employees.
- Resident grievances will be monitored continually for concerns regarding abuse.
- All SNF team members will be trained upon hire and annually to observe signs of abuse with cognitively impaired residents and report concerns to the Administrator.
- The DON or designee will audit skin checks weekly for a portion of the resident census to monitor for concerns.
- The Administrator or designee will conduct resident interviews weekly to monitor satisfaction with care and monitor for reports of abuse.
- Compliance and audit results will be monitored through the facility QAPI program, with the Administrator responsible for ongoing compliance.
Staff-to-Resident Physical Abuse During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA during incontinence care. The resident had multiple significant medical diagnoses, including severe chronic kidney disease, diabetes, hypertension, deep vein thrombosis, myocardial infarction, history of pulmonary embolism, diabetic retinopathy, delirium, dementia with agitation, pulmonary edema, and spondylosis. An MDS assessment documented severely impaired cognitive skills, and the admission assessment noted the resident had clear speech, was sometimes able to understand instructions, had a pleasant mood, no observed behaviors, was always incontinent of bowel and bladder, had no skin impairments, and ambulated with a walker. Nursing skilled notes in the days immediately prior to the incident documented no voiced complaints and no resistance to care or refusals. On the date of the incident, a change of condition form completed by the primary nurse documented that the nurse witnessed a CNA hit the resident during incontinence care after the resident became aggressive and swung at the CNA, breaking the CNA’s necklace. The form stated that the CNA punched the resident twice in the lower back with her fists. The resident then demonstrated paranoid and aggressive behaviors, refused assistance with changing, refused physical assessment, and ran into the hallway without pants, would not allow anyone to touch her, and sat in a chair in the hall with a sheet over her legs. The nurse practitioner’s note from the same day described the resident as increasingly confused, agitated, and combative, sitting in the hallway soiled in a disposable brief and refusing to allow staff to change her. The NP documented that the resident was unaware of self, surroundings, or location, was attempting to contact her father, and that a thorough review of systems and physical exam could not be completed due to the resident’s mental status. Subsequent documentation showed that after the incident the resident initially refused to speak with social services and was described as agitated, confused, and unwilling to allow staff to assess or change her until a family member arrived. Later nursing notes indicated that the resident calmed, resumed taking medications, and allowed care, with skin assessments revealing no physical injury or pain. Psychiatry later documented the resident’s report that the CNA came from behind, grabbed, and started hitting her, and that she had to defend herself until staff intervened. The facility’s investigation included written statements from the witnessing RN, who reported that the CNA pushed the resident on her side, insisted on finding her broken necklace in the bed or brief despite the resident’s request to stop, and then punched the resident in the thigh/back twice while stating, “I just don’t care anymore.” The CNA’s own written statement acknowledged the resident became combative, broke her necklace and name tag, and that the CNA continued to attempt to provide care despite the resident’s refusals. These events constituted the substantiated incident of staff-to-resident physical and verbal abuse that led to the cited deficiency.
Failure to Protect Resident From Verbal and Physical Abuse During Shower Care
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from verbal and physical abuse when a certified nursing assistant (CNA) was verbally and physically abusive during and after a shower. The resident involved had dementia, a psychotic disorder, and an anxiety disorder, but was assessed with a BIMS score of 12/15, indicating intact cognitive abilities for daily decision making. The resident required assistance with most self-care activities, including dependence for toileting, oral hygiene, and bathing. Facility documents showed that on the date of the incident, the CNA repeatedly called the resident a “witch” and, while transporting the resident in the corridor after a shower, rolled the resident in front of a fan, causing the resident to yell due to discomfort from the cold air. Interviews conducted during the survey provided additional context. The resident later stated that no staff member had mistreated her and described herself as having a bad temper and being very vocal, which she felt irritated people. Another CNA reported that the resident typically took showers without conflict, sometimes stating she was cold during care, and described the resident as not aggressive but impatient during care. An LPN explained that when residents exhibit behaviors, CNAs are instructed to ensure safety, step away, report behaviors to the nurse, and return later. Despite these expectations and prior abuse in-services completed by the CNA involved, the documented incident of name-calling and exposure to cold air during transport constituted a failure by staff to protect the resident from verbal and physical abuse.
Failure to Prevent and Care Plan Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, primarily on the memory care unit, over an extended period. Resident-on-resident altercations repeatedly occurred in which one resident struck, hit, pulled hair, or otherwise physically contacted another resident, often involving the same aggressor. For example, one resident repeatedly struck other residents in the face, head, shoulder, arm, and mouth, and pulled another resident’s hair while they were seated in the dining room. In many of these events, staff documented that the aggressor resident became agitated or combative, particularly when other residents were in her personal space, when she perceived staff as needing protection, or immediately after receiving care. The clinical records and final event synopses show that affected residents were typically seated in common areas such as the dining room or wandering on the memory care unit when they were struck or otherwise physically abused. In several cases, staff or other residents witnessed the incidents and separated the residents, and progress notes documented assessments showing either no visible injury or minor findings such as a small red spot on the nose, bruising to the upper lip, or a fall to the floor after being hit on the shoulder. Many of the residents involved had cognitive impairment and were unable to recall the incidents when interviewed afterward, though one resident later described being “whacked” across the face. Staff interviews acknowledged that residents on the memory care unit wander, can become easily agitated, and are especially vulnerable due to cognitive status and limited ability to communicate symptoms. Across all cited residents, the comprehensive care plans in place at the time of the incidents did not contain information related to these episodes of resident-to-resident abuse. Care plans for residents who were struck, hit, or had their hair pulled lacked any documentation of the abuse incidents or individualized approaches addressing these behaviors or the residents’ vulnerability to further altercations. This absence of care plan interventions was noted for multiple residents who experienced one or more abusive encounters, including those who were struck on more than one occasion by the same aggressor. Facility staff, including nursing and social services personnel, stated in interviews that any willful striking, hitting, smacking, or hair-pulling by one resident toward another constitutes physical abuse and that residents have the right to be free from abuse, consistent with the facility’s written abuse policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. In addition to the repeated incidents involving a primary aggressor on the memory care unit, other residents were abused by different residents who became combative when their personal space was invaded. In these cases, staff witnessed residents being hit on the arm or chest and a resident being struck on the shoulder, causing a loss of balance and a fall. Progress notes documented that affected residents were assessed and often had no recall of the negative encounters. Despite these documented events and staff recognition that such conduct constitutes abuse, the corresponding care plans for the abused residents did not reflect the incidents or any related information. The pattern of resident-to-resident physical abuse, combined with the lack of care plan documentation addressing these events, formed the basis of the cited deficiency and led to a determination of immediate jeopardy for residents on the memory care unit.
Removal Plan
- Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
- Provide follow up psychosocial support from social services to Residents #58, #94, #25, #13, #41, and #68.
- Screen all residents for evidence of abuse and neglect.
- Complete an abuse questionnaire for residents who are interviewable (BIMS score of 8 or greater).
- Complete a head to toe physical assessment for non-verbal residents or residents with a BIMS score of 7 or below.
- Address any identified concerns according to the HVHC Abuse and Neglect Policy.
- Conduct an audit of all incident reports for the last 30 days to ensure that all events meeting the reporting requirements were reported to the appropriate parties.
- Reeducate all staff of the facility/agency on the HVHC Abuse and Neglect Policy, including abuse prevention, types of abuse, abuse reporting, and the Elder Justice Act specifically pertaining to resident to resident altercations.
- Require any staff not present for the education to receive mandatory education prior to the start of their next shift.
- Prohibit staff from returning to work until the mandatory education has been completed.
- Include this training in new hire orientation as part of the new hire process.
- Require all agency staff to complete this education prior to starting work in the facility.
- Provide reeducation to facility leadership (NHA, DON, social services, activities) on abuse reporting and investigating allegations of abuse and resident altercations.
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