Failure to Follow Transfer Protocols Results in Resident Injury
Summary
The facility failed to protect a resident's right to be free from abuse and neglect by not ensuring staff followed the resident's care plan for safe transfers. On the morning of November 7, two CNAs did not adhere to the care plan that required the use of a mechanical lift with the assistance of two staff members for transferring the resident from bed to wheelchair. Instead, they manually lifted and pivoted the resident, resulting in the resident experiencing extreme pain in his right leg shortly after the transfer. The resident, who was cognitively intact and had bilateral lower extremity impairment, was dependent on staff for all care and was determined to be non-weight bearing. The care plan, revised earlier, specified the need for a mechanical lift due to the resident's physical limitations and safety concerns. Despite this, the CNAs proceeded with a manual transfer, leading to a right distal femur fracture, which was confirmed by an X-ray. The resident was subsequently transferred to the hospital for evaluation. The incident was compounded by a lack of communication and adherence to protocol among the staff. CNA A, who was responsible for the transfer, did not check the resident's transfer status on the Kardex and instead relied on verbal information from another CNA. This oversight, coupled with the decision to proceed without the mechanical lift due to time constraints, directly contributed to the resident's injury. The facility's failure to ensure staff followed the care plan placed the resident and others requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident #1 was immediately assessed, X-ray completed and pain medication given. He was sent to emergency room.
- CNAs A and B were removed from service immediately and interviewed about the transfer.
- Residents' Plan of Care (POC)/Kardex reviewed prior to receiving care from Nursing Staff.
- Education of staff begun on all shifts regarding the importance of following residents' POC of transfer status and where to obtain transfer status from Kardex.
- 70 day shift staff, 20 evening shift staff, 11 night shift staff provided education that included post test of reporting of any allegation of abuse/neglect/exploitation (ANE), who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- A group discussion with CNAs to ask what their barriers may or may not be to following POC and the importance of communicating those barriers immediately to their supervisor.
- All residents were reviewed to ensure POC accuracy for transfer.
- Interviews were conducted with 9 residents on the CNA's assignment to verify that staff are consistently following care planned transfer status.
- Interviews were conducted with 41 interviewable residents regarding abuse and neglect to determine any other concerns.
- Any staff member not present were educated prior to starting their shift.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting held and attended by Administrator, Director of Nursing, Medical Director and Interdisciplinary team to review incident and investigation.
- 13 Clinical Nursing Staff on 7AM-3 PM shift, 8 Clinical Nursing on 3 PM-11 PM shift, and 5 Clinical Nursing Staff on 11 PM-7AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Another Ad Hoc QAPI meeting with Administrator, Director of Nursing, Medical Director, Company President, Chief Nursing Officer, Regional Plant Operations Director and Interdisciplinary team to review incident and investigation.
- 8 Clinical Nursing Staff on 7 AM-3 PM shift, 6 Clinical Nursing Staff on 3 PM-11 PM shift, and 4 Clinical Nursing staff on 11 PM -7 AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex. Any Clinical Nursing staff member not present received education prior to their shift. Education was continued regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- An Ad Hoc QAPI meeting attended by Regional Director of Operations, Quality Management Specialist, Nursing Home Administrator and Director of Nursing. Discussion completed to include needed re-education regarding where to find transfer status on the Kardex, ANE continued education review of assignments, review of current status of lifts/batteries. Review of monthly lift inspections- review of interviews and re-enactments.
- Education was continued with staff regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care. 22 additional staff were provided education.
- Nurse Leadership completed quality monitoring, on all three shifts, to include verbal review and/or return demonstration to ensure following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer - completed on all three shifts.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held included review of education completed, and individual phone calls continued regarding mandatory education needed- staff to sign education and post test prior to working.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts.
- Daily room rounds completed with guardian angel rounds-completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working, discussed need to review Facility Assessment.
- Continued audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts. Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers, continued.
- 100% of Nursing staff was trained regarding resident transfer status, where to obtain information on the Kardex, and regarding Abuse and Neglect to include post test- (1 employee out of the country and 1 on family medical leave).
- Monthly QAPI meeting held-Facility Assessment reviewed, education, audits, post test reviewed- IDT has determined compliance. DON/designee will continue to complete random audits/observations of resident transfers to evaluate ongoing compliance. DON/designee will continue to complete random audits/interviews of staff to validate staff can articulate abuse/neglect reporting process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of CVA, depression, anxiety, and moderate cognitive impairment, whose care plan included emotional support and reassurance, was involved in an incident where an RN reacted to the resident’s loud swearing and use of religious profanity by stating she was consecrated to the Lord and then spraying holy water twice in the resident’s direction from a spritzer bottle the RN carried. The resident had not agreed to this, was visibly bothered, and later reported to an LPN that someone had sprayed her in the face with something. The RN admitted to the LPN that she sprayed holy water at the resident because of the resident’s use of the Lord’s name in vain, and the resident became very agitated and confrontational afterward, leading to a finding of staff-to-resident physical abuse and inappropriate treatment.
Two residents were subjected to verbal abuse by nursing staff. One cognitively impaired, fully dependent resident with dementia and other comorbidities was recorded on video while an LPN loudly scolded her during incontinence care, threw soiled washcloths onto the floor, and shouted about not being an aide, while CNAs later referred to the resident’s daughter as a "spy" and discussed her visitation restrictions within the resident’s hearing during a mechanical lift transfer. Another cognitively intact resident with multiple medical conditions and elected video monitoring was the subject of a personnel report documenting that an LPN was seen on video shouting at him and using foul language, and a family member later submitted a written concern about the LPN’s behavior, which was characterized in the counseling as disrespectful, abusive, and unprofessional.
A resident with severe dementia and a documented history of aggressive behaviors, including hitting and wandering into other residents’ rooms, was in a common area when this resident struck another cognitively impaired resident in the chest. A CNA heard yelling, observed the strike, and intervened, and the injured resident immediately reported pain. Over subsequent days, the injured resident continued to complain of significant left chest and breast pain, with high pain scores and documented discoloration, requiring repeated assessments, imaging, and pain management, and was ultimately sent to the ER where additional traumatic findings were identified. Despite a written abuse policy defining physical abuse as hitting and requiring prompt reporting of alleged abuse to the state agency, the DON acknowledged that the facility did not self‑report the resident‑to‑resident altercation because the resident was considered not injured, demonstrating a failure to provide adequate supervision to prevent abuse and to follow abuse reporting procedures.
A CNA with a documented history of poor customer service and unprofessional behavior repeatedly used a rude, loud, and disrespectful tone toward residents and staff, including telling a resident that if she could not be patient she would be moved to a “bad hall” where it would take longer to receive help. Staff, including an LPN and a unit manager, reported witnessing the CNA raising her voice in hallways, yelling in the halls and at the nurses’ station, and making loud, demeaning comments about a resident who refused a shower. These actions occurred despite a facility policy requiring immediate reporting of suspected abuse or neglect to administration and state authorities.
A resident with anxiety, major depressive disorder, and a history of childhood sexual abuse reported becoming emotionally upset after receiving an incest-themed YouTube video from a staff member through Facebook. The cognitively intact resident stated the video was triggering given her past abuse, and also reported hearing that others had complained about her body odor on social media. The staff member admitted being Facebook friends with the resident and sending the video because he thought it was humorous, while denying making comments about her odor. The facility’s investigation, confirmed by the DON and Administrator, found that the staff member’s social media interaction and transmission of the video constituted emotionally abusive conduct toward the resident.
An LPN who appeared impaired, was falling asleep while standing, dozing off during conversations, and dropping medications was allowed to continue working a full shift despite multiple reports from residents and staff to an on‑call LPN. The DON and Administrator were not fully informed that day, and the LPN was not removed from resident care. As a result, multiple residents with complex conditions such as COPD, DM2, CHF, seizures, anoxic brain damage, CKD, and depression did not receive numerous ordered medications, tube feedings, PEG flushes, respiratory treatments, blood glucose checks, insulin doses, pain assessments, behavior monitoring, head‑of‑bed elevation, enhanced barrier precautions, and other prescribed interventions during that shift, as later confirmed by EMR, MAR, and TAR review by the DON.
Staff-to-Resident Abuse Involving Spraying Holy Water Without Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from staff-to-resident physical abuse when an RN attempted to spray holy water on the resident without consent. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, aphasia following cerebral infarction, major depressive disorder, anxiety disorder, and a need for assistance with personal care. The resident’s care plan addressed depression with interventions such as reassurance, diversional activities, decreased stimuli, and allowing the resident to vent feelings, and also addressed emotional issues related to a prior CVA. A quarterly MDS assessment documented moderate cognitive impairment and no physical or verbal behaviors. The incident occurred when the resident was conversing with another resident, during which they were swearing, using curse words, and laughing. According to the RN’s own statement, the two residents were swearing loudly and using an explicit word alongside the name of Jesus. The RN reported that she reminded them to be quieter because it was late. When the resident began to “insult the Lord,” the RN told the resident that this hurt her because she was consecrated to the Lord and then stated she had holy water that might help the resident be nicer. The RN had a spritzer bottle of holy water on her person that she used on herself and then spritzed it twice in the direction of the resident from about six feet away. The resident did not agree to this action and was visibly bothered by it. The resident subsequently reported to an LPN that someone had sprayed her in the face with something. The LPN then approached the RN at the nurse’s station, and the RN admitted she had sprayed the resident with holy water due to the resident using the Lord’s name in vain. The RN further reported that the resident became very agitated, red-faced, pointing, swearing, and continued to threaten the RN’s safety after the spraying. The facility determined that the RN did not provide appropriate behavioral intervention and that the conduct constituted inappropriate treatment and physical abuse related to the imposition of religious beliefs and spraying holy water toward the resident without consent.
Failure to Protect Residents From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. One resident with Alzheimer's disease, CHF, anxiety, seizures, cognitive deficit, and total dependence for care had a family-installed camera and a personal care companion. Video from the resident's room showed an LPN assisting a CNA with incontinence care, loudly telling the resident to stop squeezing her buttocks and yelling to the resident's daughter to tell the resident to stop. The LPN threw dirty washcloths over the bed onto the bare floor and loudly stated she was not an aide and was doing the best she could. During this care, the resident, who was non-verbal, was observed grunting, moaning, crying out, and swinging her arms until the family caregiver came to comfort her. In a separate video, two CNAs providing care and transferring the same resident via mechanical lift were heard referring to the resident's daughter as a "spy" and stating they had to do care a certain way because that was how the "spy" wanted it done, and further stating that the daughter was not allowed in the facility and could not visit on the resident's birthday, all while providing care in the resident's presence. Another resident, with diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, had intact cognition and had elected to have video monitoring in his room. Review of the personnel file for an LPN revealed a Corrective Action Report documenting that, on one date, the LPN was observed on video shouting at this resident and using foul and cursing language, and on another date a family member submitted a written concern regarding the LPN's behavior toward them. The written counseling described the LPN's behavior as disrespectful, abusive, and unprofessional. The facility's abuse policy defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Response to Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with known aggressive behaviors and to provide adequate supervision to prevent such abuse. One resident with severe dementia and a documented history of delusions, physical and verbal behaviors, rejection of care, wandering, and physical aggression toward others was care planned for multiple behavioral symptoms, including hitting, kicking, pushing, grabbing, and entering other residents’ rooms. Interventions in the plan of care included medication management, calm approaches, communication before care, leaving and returning if the resident resisted care, observing and documenting inappropriate behaviors, notifying the practitioner when behaviors persisted, providing psychological/psychiatric services as needed, offering choices, and providing a calm, safe environment and structured daily schedule. Despite this, the resident with aggressive behaviors was in a common area where another severely cognitively impaired resident was present. On the date of the incident, a CNA reported hearing yelling in a common area and then observed the aggressive resident strike another resident in the left side of the chest. The CNA immediately intervened and separated the residents. The nurse assessed the resident who was struck and initially found no redness or bruising, with stable vital signs. The resident reported that it hurt and did not know why the other resident had hit her. Over the following days, the resident continued to complain of left chest and breast pain, with pain scores documented as high as 9–10 out of 10. Multiple assessments and diagnostic tests were performed, including chest x‑rays and pain assessments, and the resident was repeatedly administered acetaminophen and topical agents for pain. Notes documented ongoing pain, intermittent anxiety, and discoloration to the left chest. The resident’s pain and chest symptoms persisted, leading to additional diagnostic workup including a STAT chest x‑ray, EKG, troponin level, and eventually transfer to the emergency room after family involvement and insistence on hospital evaluation. In the ER, imaging identified findings including an abdominal aortic dissection and other abnormalities, and the family reported that the ER physician questioned whether the injury pattern could be related to trauma. The family member also reported that the resident had slight discoloration to the chest from being hit and that the hospital took photographs. The DON later stated that the facility did not complete a self‑reported incident to the state agency regarding the altercation between the two residents because the resident was considered not injured. The facility’s abuse policy defined physical abuse to include hitting and punching and required reporting alleged violations to the state agency within specified timeframes, including immediately but not later than two hours after an allegation involving abuse or resulting in serious bodily injury. Despite this policy and the known aggressive behaviors of the resident who struck the other resident, the facility did not self‑report the incident.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to ensure a verbal abuse–free environment. Certified Nursing Aide (CNA) #114 had a documented history of poor customer service and unprofessional behavior, including being rude and negative toward residents and coworkers, as reflected in multiple corrective action and employee counseling forms. On at least two occasions in late 2025, CNA #114 was counseled for failing to maintain respect for residents and for poor customer service. Staff statements described ongoing concerns that CNA #114 used a rude, dismissive, and disrespectful tone with residents and staff, lacked empathy and patience when providing care, and yelled in the hallways. A specific incident involved Resident #75, who reported to the Administrator that CNA #114 had been mean to her since admission. The resident stated that when she asked for help, CNA #114 told her that if she could not learn to be patient, she would be moved to the “bad hall,” where there were more residents and it would take even longer to receive help. Other staff corroborated concerns about CNA #114’s verbal interactions with residents. A typed statement from an LPN described having to verbally educate CNA #114 about her tone of voice toward a resident in a dining room, reminding her that the facility was the residents’ home and that discussions should occur privately due to residents and family members being present. Additional staff statements from a Unit Manager and another LPN detailed observations within the preceding weeks of CNA #114 being loud, rude, and unprofessional toward both residents and staff. The Unit Manager reported witnessing CNA #114 raising her voice in hallways and discussing residents loudly enough for others to overhear, including a comment that a resident who refused a shower “stinks and needs to shower.” Another LPN reported witnessing CNA #114 yelling in the halls and at the nurses’ station on several occasions. The Director of Nursing stated that CNA #114 was no longer allowed to work on a particular unit because she was not allowed to care for a resident there and noted that other staff experienced her as rude and disrespectful when asked to complete tasks. These events occurred despite a facility policy requiring immediate reporting of suspected abuse, neglect, or related concerns to the Administrator and state authorities.
Failure to Prevent Emotional Abuse via Staff Social Media Interaction
Penalty
Summary
The facility failed to protect a cognitively intact resident from emotional/verbal abuse when a staff member engaged with the resident through personal social media and sent her an upsetting video. The resident, who had diagnoses including generalized anxiety, major depressive disorder, and insomnia and used a motorized wheelchair, reported to nursing staff that she was emotionally upset after receiving a YouTube video titled "Folgers Incest Commercial" via Facebook from an employee with whom she was Facebook friends. The video depicted a brother and sister in a romantic and sexual relationship. The resident also reported that she had used vaginal soap to eliminate odors after hearing that others had complained about her smell and posted about it on Facebook. During the facility’s investigation, the resident consistently stated that she found the video emotionally upsetting and triggering due to her personal history of sexual abuse by her father and brother during childhood. The employee acknowledged being Facebook friends with the resident and confirmed that he had sent her the video because he thought it was funny, stating he was unaware of her sexual abuse history and denying that he had made any comments about her body odor. The DON and Administrator confirmed that the investigation substantiated that the employee had sent the incest-themed video to the resident via social media, and the facility concluded that the employee’s actions were emotionally abusive and upsetting to the resident.
Failure to Remove Impaired LPN Resulting in Widespread Missed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by allowing an LPN who appeared to be under the influence of an unknown substance to continue providing care and medications throughout a full shift. Multiple residents and staff observed the LPN on a specific date appearing impaired, including falling asleep while standing, dozing off mid-conversation, appearing disheveled and very tired, and dropping medications on the floor before administering them. Residents reported late medication administration and, in at least one case, receiving pain medication after it had been dropped on the floor. Staff, including another LPN and a CNA, repeatedly contacted the on‑call manager (an LPN) to report the LPN’s erratic behavior and residents’ complaints about not receiving medications, tube feedings, treatments, and other ordered interventions. Despite these reports, the impaired LPN was not removed from resident care during that shift, and the DON and Administrator were not directly notified of the extent of the behavior on that date. The on‑call LPN spoke with the impaired LPN by phone, accepted the explanation that the LPN was tired from lack of sleep, and did not escalate the concerns to the Administrator that day. The DON later stated she was not made aware of the full extent of the erratic behavior at the time and confirmed that the LPN completed the scheduled shift and returned to work the following day. Residents subsequently reported the LPN’s behavior and the missed or improperly administered medications to the DON and Administrator. Record review showed that numerous residents assigned to this LPN did not receive multiple physician‑ordered medications, treatments, assessments, monitoring, and safety interventions during that day shift. For example, one cognitively intact resident with alcohol abuse, depression, anxiety, HTN, insomnia, and vitamin deficiencies did not receive ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, paroxetine, or a required pain assessment. Another resident with severe cognitive impairment, anoxic brain damage, heart failure, CKD3B, chronic respiratory failure, seizures, PBA, depression, anxiety, and dysphagia missed multiple cardiac, antiplatelet, anticonvulsant, psychotropic, pain, and behavioral medications, as well as ordered head‑of‑bed elevation, pain assessment, behavior monitoring, diet communication, and clothing interventions. Additional residents with complex conditions such as anoxic brain damage with PEG tube and tracheostomy, severe malnutrition, COPD, DM2, CVA, seizures, CHF, prostate cancer, and other chronic diseases did not receive ordered cardiac, anticoagulant, antiplatelet, respiratory, diabetic, seizure, GI, nutritional, and pain medications, PEG tube feedings and flushes, oxygen saturation checks, blood glucose monitoring, insulin administration, head‑of‑bed elevation, enhanced barrier precautions, behavior monitoring, and safety signage during that shift, as confirmed by the DON through EMR, MAR, and TAR review. The DON verified that, for each of the affected residents, the specific physician‑ordered medications and treatments listed in the EMR, MAR, and TAR were not provided during the day shift covered by the impaired LPN. These omissions included, but were not limited to, antihypertensives (such as amlodipine, carvedilol, lisinopril, metoprolol, minoxidil), antiplatelet and anticoagulant agents (aspirin, clopidogrel, apixaban), anticonvulsants (levetiracetam, valproic acid, clobazam, Depakote Sprinkles), psychotropics and anxiolytics (sertraline, duloxetine, quetiapine, buspirone, diazepam, paliperidone), diabetic medications and insulin (metformin, glipizide, insulin glargine, insulin aspart), respiratory medications and inhalers (Anoro Ellipta, Breo Ellipta, Incruse Ellipta), GI agents and supplements (omeprazole, pantoprazole, lactulose, MiraLAX, Jevity tube feedings, PEG flushes, vitamins, potassium, magnesium), pain medications and lidocaine patches, as well as ordered assessments such as pain scales, behavior monitoring, head‑of‑bed elevation, oxygen saturation checks, blood sugar checks, PEG placement and residual checks, diet communication, enhanced barrier precautions, and safety signage. These documented failures occurred while the LPN was reported by residents and staff to be acting impaired and while the facility did not effectively intervene to remove the LPN from resident care or ensure completion of the ordered care during that shift.
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