Failure to Prevent Resident-to-Resident Abuse
Summary
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. On one occasion, a resident with a history of aggression due to dementia struck another resident in the face with a walker, causing lacerations and bruising. The aggressive resident had a known history of physical and verbal aggression and was supposed to have a stop sign across their door to prevent others from entering, but it was unclear if this was in place at the time of the incident. The injured resident, who was cognitively impaired and had a hearing deficit, was in pain and required medication following the incident. In another series of incidents, two residents who were roommates engaged in physical altercations on multiple occasions. Both residents had cognitive impairments and histories of aggressive behavior. Despite being placed on 15-minute checks after the first altercation, they remained roommates and continued to have conflicts, including slapping each other and being found crawling on the floor after a struggle. The facility was aware of the incompatibility between the two residents but did not have alternative accommodations available on the secure unit. The facility's policies on abuse prevention and reporting were not effectively implemented, as evidenced by the repeated incidents of resident-to-resident abuse. Staff interviews revealed that there were concerns about the aggressive behaviors of certain residents, but these concerns were not adequately addressed to prevent harm. The facility's failure to ensure proper supervision and intervention contributed to the incidents, and there was a lack of documentation regarding preventive measures such as the placement of stop signs.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. As per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. - A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there are no ongoing negative psychosocial impact. - Additional signage will be placed on the resident’s door to deter others from wandering into the resident’s room. - Certified Nursing Aide #1, Social Worker #1, Registered Nurse Head Nurse #2 and Licensed Practical Nurse #1 will receive educational counseling on their role to identify potential for abuse and prevent abuse from occurring including ensuring that preventative measures such as stop signs were in place per plan of care. - Resident #17: - An assessment by a Registered nurse was completed on each altercation between resident #17 and #75. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact due to the altercations and the subsequent room changes. - Resident #75: - An assessment by a registered nurse was completed upon each altercation with resident #17. No injuries were identified. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. - Resident #75 was moved to a private room on a different unit. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations. - Licensed Practical Nurse #1 and Certified Nursing Aide #1 will be educated on their role to report resident issues including resident to resident verbal altercations immediately. - Registered Nurse #1 will be educated on their role to put interventions into place to prevent/reduce risk of abuse and prevention of recurrence. - The Director of Nursing and Assistant Director of Nursing were educated on their role to investigate reports of verbal altercations between residents as potential incidents of abuse and institute measures to prevent recurrence. II. As per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed to identify any incidents of actual or potential abuse, neglect or mistreatment. - The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. As per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect – Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - The facility Comprehensive care planning policy was reviewed and updated by the consultant with administration and nursing leadership to include the requirement to revise the care plan with interventions to prevent recurrence of incidents including abuse. - As per the Directed Plan of Correction, the Consultant has developed and will implement an In-service Program to address: - Abuse Identification, Prevention and Reporting: - All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: - The Administrator, Director of Nursing and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved. - Regulatory Changes: - All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. - Care Planning: - All nursing leadership and social work staff will be educated by the consultant on the care plan policy updates specific to identifying Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, initiating interventions to prevent or reduce the risk of abuse and revising care plan with interventions to prevent recurrence of abuse. - The facility will monitor for increase resident-resident altercations and or injuries of unknown origin that may signal or alert staff that a problem is potentially evolving. - All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: - As per the Directed Plan of Correction, a Quality Assurance Committee meeting was held on (MONTH) 24, 2024, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plan updated accordingly. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assurance Committee monthly for three months. The consultant will participate in Quality Assurance for three months. Frequency of ongoing audits will be determined by the Committee based on audit results. - Consultant will participate in the Quality Assurance Committee Meeting monthly x 3 months. The administrator will be responsible to ensure corrective action is implemented.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
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