Failure to Protect Resident from Abuse
Summary
The facility failed to protect a resident from staff-to-resident physical and verbal abuse, resulting in Immediate Jeopardy. On the evening of May 19, 2024, a Registered Nurse (RN) was observed by two State Tested Nursing Assistants (STNAs) swearing and yelling at a cognitively impaired resident in the memory care unit. The RN removed the resident from the dining room, took her to her room, and slammed the door. The RN remained alone with the resident for approximately 10 to 15 minutes, during which time the STNAs heard the resident crying louder. After the RN exited the room, the resident was found crying with blood spots on her Geri sleeves and a bruise on her hand. A total of nine wounds were later confirmed by a Wound Care Certified Nurse Practitioner. The facility did not take immediate action to protect the resident or investigate the incident thoroughly. Despite the severity of the situation, the RN was allowed to return to work with the resident unsupervised on May 27, 2024. Interviews with staff revealed that the RN had previously expressed frustration with the resident and had been reported for using profanity towards her. The facility's failure to recognize and appropriately respond to the abuse allegation resulted in the resident experiencing severe psychosocial harm. The resident involved had a history of neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder, and Pseudobulbar affect, which made her severely cognitively impaired. She required assistance with activities of daily living and used a wheelchair for mobility. Prior to the incident, there were no documented skin tears or bruises on the resident. The facility's lack of effective interventions and failure to conduct a thorough investigation contributed to the deficiency.
Removal Plan
- RN #521 notified Resident #19's daughter/Power of Attorney (POA) of new skin tears and bruising to the resident's arms.
- RN #521 notified Assistant Director of Nursing (ADON) #522 Resident #19 had skin tears and bruising to bilateral arms.
- ADON #522 notified the Administrator of the skin tears and bilateral bruising to the arms on Resident #19.
- The Administrator notified RDCS #510 of Resident #19's skin tears and bilateral bruising to the arms.
- The Administrator notified RDO #503 of Resident #19's injuries.
- The Administrator opened an SRI for an injury of unknown origin.
- The Administrator interviewed RN #521, via phone, regarding Resident #19's injuries.
- RN #521 notified CNP #524 of Resident #19's new skin tears and bilateral bruising to arms. New orders were obtained for bilateral x-rays of hands and arms.
- The Director of Nursing (DON) interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 was suspended pending the outcome of the investigation.
- Assistant Administrator (AA) #523 interviewed 12 random staff regarding witnessing abuse or reporting abuse, with no findings.
- ADON #522 initiated Residents Rights and Abuse Inservice for all staff.
- Resident #19 was seen by CNP #524. New orders were received for oxycodone for pain from skin tears and bruising and Keflex (antibiotic) for prevention of infection from skin tears.
- CNP #524 ordered Resident #19's assist rails be removed from the resident's bed to reduce risk of injury.
- Laboratory (lab) orders, which included a Complete Blood Count (CBC) with differential, was completed for Resident #19.
- Resident #19's lab results were received and reported to the physician. No new orders were received.
- The Administrator and DON re-interviewed RN #500. No additional information was obtained.
- An x-ray was completed for Resident #19's bilateral arms and hands.
- Resident #19 was evaluated by WCCNP #502 for skin tears to bilateral arms.
- ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe with no negative findings.
- ADON #522 completed skin assessments of all residents on the memory care unit with no negative findings.
- Resident #19 was evaluated by Medical Director (MD) #750. No bruising was noted to the resident's face at the time of the examination. A new order was received for referral to hematology.
- X-ray results of bilateral arms and hands received for Resident #19 with no fractures identified.
- The SRI for injury of unknown origin was closed with an unsubstantiated finding.
- The DON informed RN #500 Resident #19's family requested, due to the incident, she no longer work with the resident. RN #500 was offered the option to work on another unit.
- Resident #19 was seen by psychiatric services, Psychiatric CNP (PCNP) #700, with no negative findings.
- Resident #19 was evaluated by hematology and no new orders were received.
- The Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19's injuries.
- The Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 and abuse likely occurred.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse.
- RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility's abuse policy and prevention, reporting and investigation of allegations of abuse.
- The Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse involving RN #500.
- The Administrator filed a police report with the local police department related to suspected staff-to-resident abuse.
- Department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy.
- AA #523 completed interviews with all staff who worked on specific dates.
- RDCS #510, RDO #503 and the Administrator interviewed WCCNP #502 regarding Resident #19's injuries.
- The DON and ADON #522 completed skin audits on all residents.
- The Administrator will review all potential SRIs with VPO #640 and VPCS #641 to ensure the appropriate SRI category is filed and thoroughly investigated.
- The Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff.
- VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks.
- RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation was completed.
- The Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed.
- The DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse.
- SSD #535 will meet with Resident #19 three times weekly for four weeks to assess psychosocial well-being and provide additional support.
- Results of audits will be reviewed at the QAPI meeting weekly for four weeks, then monthly thereafter to determine on-going compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An agency NA forcefully pushed a wheelchair-bound resident through a doorway while the resident was caught in the frame, causing the resident’s foot to strike both shins and resulting in bruising, swelling, pain, and an acute right tibia fracture. The resident had dementia, muscle weakness, and required assistance with mobility and transfers. CCTV and the facility’s investigation showed the NA did not follow safety measures during the transfer.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to Protect Resident During Transfer Resulted in Right Tibia Fracture
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when an agency nurse aide forcefully handled Resident R86 during wheelchair transport. CCTV review showed the aide pulling the resident as she was caught in a doorway, then attempting to push her through the doorway forcefully. During this event, the resident’s right foot became caught on the doorframe and struck her right shin, then her left shin, before she was pushed through the doorway. Resident R86 was admitted to the facility with diagnoses including hypertension, vascular dementia, muscle weakness, and cognitive communication deficit. The resident’s MDS indicated dependence for multiple mobility-related activities and use of a wheelchair. The care plan noted that the resident could move around the facility without supervision but could not exit without supervision, and later documented bruising to both lower extremities, swelling of the lower right extremity, and a right tibia fracture, with bed rest and Hoyer transfers for all transfers. After the incident, bruising was documented on the resident’s lower extremities, including dark purple/green bruising to the right shin and swelling and pain in the right leg. The resident was unable to tolerate range-of-motion assessment because of pain and agitation. X-rays later showed an acute mildly displaced spiral fracture below the level of the tibial prosthetic stem in the right tibia. The facility’s investigation concluded that the nursing aide neglected to follow facility safety measures.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Delayed Reporting of Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when continued nonconsensual sexual contact occurred between two roommates. Resident 1 had diagnoses including schizophrenia and a BIMS score of 9, indicating moderate cognitive impairment. Resident 2 had a BIMS score of 15, indicating normal cognitive function. According to the resident’s statement, Resident 2 kissed his body and engaged in sexual contact that Resident 1 did not consent to, including manual genital manipulation, kissing and licking of his body, and anal penetration. A nurse aide heard Resident 1 say that Resident 2 liked to kiss his body and later questioned him about whether Resident 2 asked him to do things he did not want to do. Resident 1 responded that Resident 2 “jerks me off” and said it happened often. The nurse aide stated that he or she was unsure what to do and did not feel comfortable talking to anyone except the unit manager. The unit manager’s statement indicated that the nurse aide reported the allegation four days after the initial disclosure. Resident 2 also acknowledged sexual contact, stating that he had kissed Resident 1 all over his body and touched his private area, and said the last contact occurred two nights before the interview. The resident was evaluated in the ED for sexual assault, and the facility later substantiated sexual abuse based on the delayed reporting by the nurse aide. The report identified that the delay in reporting allowed further nonconsensual sexual contact to occur before the allegation was acted upon.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Verbal Abuse During Hospital Discharge Discussions
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by facility staff. The resident had diagnoses including frontal lobe and executive function deficit, stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis, and the record also documented the resident as cognitively intact. The resident had been admitted on 01/17/2025 and was transferred to the emergency department on 6/18/2026 for further evaluation and treatment related to possible infection, weakness, dizziness, pallor, and low potassium. After the hospital transfer, the resident stated that facility leaders told the resident the facility would not allow the resident to return because there were no available beds. The resident reported that the administrator and DON came to the hospital, that the administrator, DON, company owner, and corporate administrator were on speaker phone, and that the administrator and DON were verbally abusive, yelled at the resident, and said the resident had behavioral issues, owed the facility a lot of money, and was a bad person. The resident stated feeling pressured, outnumbered, and extremely insignificant, and said the resident never told staff not to return until being told the facility did not want the resident back. Hospital staff corroborated the resident’s account. The hospital social worker stated the facility refused to accept the resident back, that the DON was rude, unpleasant, and harassed the resident in the emergency department waiting room, and that the administrator and DON were aggressive and yelled at the resident during the discussion about returning to the facility. The hospital case manager stated the administrator and DON told the resident about problems the resident had caused for the facility and said the resident could return if the resident paid on the bill. The administrator later stated that staff had to yell because the resident was hard of hearing and acknowledged that the conversation involved reviewing the letter and bullet points about what led to the situation.
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