F0600

D

Physical Abuse of Cognitively Impaired Resident by Nurse Aide

Ebensburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident from abuse when a nurse aide physically struck the resident during an interaction in the resident's room. Facility policy dated September 23, 2025, stated that abuse, neglect, mistreatment, exploitation, and misappropriation of resident property would not be tolerated. Resident 2 had an admission MDS dated December 7, 2025, indicating cognitive impairment, dependence on staff for all care needs, and a diagnosis of Alzheimer's disease. On December 15, 2025, at approximately 6:11 p.m., during supper, the resident attempted to self-propel out of the room and grabbed another resident's bed to assist with movement. According to a nurse's note and an event report, Nurse Aide 2 responded by grabbing the resident's hands to make him let go of the bed and pushing him away, which caused the resident to become agitated and again grab the bed.

A witness statement and interview with Nurse Aide 1, who observed the incident, revealed that after the resident again grabbed the bed, Nurse Aide 2 forcefully removed the resident's hands, leading the resident to grab the aide's arm and tell him to stop. Nurse Aide 2 then removed the resident's hands from his arm and struck the resident's left wrist with his fist, after which the resident said, "ouch that hurt" and held his arm. Nurse Aide 2 then pushed the resident out of the room into the lounge. A subsequent skin check documented small, deep purple bruises on both of the resident's hands, though the resident was able to move both hands without signs or symptoms of pain or swelling. The regional director of clinical services later confirmed that the allegation of abuse by Nurse Aide 2 toward this resident was investigated and substantiated.