Failure to Prevent Resident-to-Resident Abuse Resulting in Fatal Hip Fracture
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident abuse, resulting in one resident pushing another resident to the floor and causing a left hip fracture that required surgery and was listed as the immediate cause of death. The resident who was pushed (R157) had severe cognitive impairment with a BIMS score of 3 and multiple diagnoses including dementia without behavioral disturbance, schizoaffective disorder, anxiety disorder, psychosis, repeated falls, weakness, unsteadiness on feet, reduced mobility, COPD, osteoporosis, heart failure, and depression. She was known to pace the unit, ask repetitive questions, display anxiety, and exhibit verbal/physical expressions related to rejection of care and delusions, as well as other behaviors such as pacing and picking at her skin. Her care plan identified her as at risk for falls related to cognitive deficits, altered safety awareness, need for ADL assistance, incontinence, and use of psychotropic and opioid medications. The resident who pushed her (R136) also had severe cognitive impairment with a BIMS score of 2–3 and extensive psychiatric and neurologic diagnoses including Alzheimer’s disease, paranoid schizophrenia, dementia with agitation, delusional disorders, depressive episodes, and severe dementia with psychotic disturbance. Her MDS and care plan documented a history of verbal and physical behaviors directed toward others, rejection of care, wandering, exit-seeking, and territoriality when others entered her room or personal space. Progress notes described that she might scream, curse, shove, kick, hit, or scratch staff providing care, and that she had been placed on a behavior tracking program for increased wandering and exit-seeking. Staff notes also documented an incident where she was kissing a relative in the dining room and became verbally upset when separated, and that she had verbal/physical behaviors related to rejection of care, with formal behavioral programming in place. On the day of the incident, R157 was walking laps on the unit, consistent with her usual pacing behavior, and walked past the doorway of R136’s room, stopping approximately 5–6 feet outside the doorway while saying something and pointing her finger. A CNA (V19) witnessed R136 come out of her room running with both arms extended and push R157 to the floor, then run back into her room laughing and shut the door. The CNA reported that R157’s head hit the floor very hard, and she was bleeding, crying in pain, and complained of severe pain everywhere. The nurse’s fall event documentation and progress note recorded that a loud noise was heard, R157 was found on the floor on her left side with painful and limited ROM in the left lower extremity, shallow skin tears to the left eyebrow and forearm, and severe pain. The fall safety event and hospital ER note both documented that another resident pushed her in an unsupervised context. Hospital records confirmed a proximal left femur fracture requiring ORIF, and the death certificate listed the acute displaced left femur intertrochanteric fracture, status post intramedullary nail insertion, with underlying dementia and contributing pulmonary edema and schizoaffective disorder, as the causes of death. Staff interviews indicated that some staff were aware that both residents had behavioral issues, though they generally described R157’s behaviors as not directed toward other residents and R136’s behaviors as primarily verbal toward staff. However, the CNA who witnessed the event stated that prior to this incident, R136 had “a few issues” at the supper table where she would put her hands on residents who annoyed her and that she was easily annoyed by other residents. Another CNA reported that R136 stayed in her room most of the time but would verbally curse or tell other residents to stay away, and staff would attempt to redirect her with snacks, TV, or diversion. The facility’s Abuse Prohibition and Reporting Policy stated that special attention would be given to identifying behaviors that increase a resident’s potential for abusing others or being a victim of abuse, including residents with a history of aggressive behaviors and those who enter other residents’ rooms. Despite documented behavioral histories and risk factors for both residents, the incident occurred when R157 was walking independently on the unit and R136 was able to leave her room and physically push R157 in the hallway, resulting in the injury and subsequent death. The facility’s internal investigation concluded that the root cause of the fall was directly linked to the actions of R136, who pushed R157, and that due to R136’s cognitive status she was unable to account for or explain her actions. The investigation noted that neither resident could provide credible details of the fall or what led up to it, and that staff who were nearby did not witness any behaviors immediately beforehand that would indicate the event would occur. The investigation also stated that R136 had no prior physical incidents since admission and that there was no sufficient evidence to suggest the actions were intentional. Nonetheless, the event met the facility’s own definition of abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, where “willful” means the individual acted deliberately, regardless of intent to cause harm. The deficiency centers on the facility’s failure to prevent this resident-to-resident abuse, despite known behavioral risks and documented patterns of wandering, territoriality, and behavioral expressions in both residents. The Medical Director later stated that, in her opinion, the incident between the two residents was unexpected and that neither resident had displayed physical behaviors toward others, and she attributed the resident’s death to poor postoperative monitoring at the hospital. However, the death certificate and hospital documentation directly linked the acute displaced left femur fracture, caused by the push and fall, to the resident’s death. The facility’s abuse policy emphasized protecting residents from all types of abuse and giving special attention to residents with aggressive behaviors or those who enter other residents’ rooms, but the events described show that R157 was able to ambulate independently in the hallway near R136’s room and that R136 was able to exit her room and physically push her, resulting in serious injury. These facts and observations form the basis of the cited deficiency for failure to protect residents from abuse, specifically resident-to-resident abuse.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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