Failure to Prevent Neglect Due to Inadequate Staffing and Improper Transfers
Summary
The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing sufficient, qualified staff and by allowing untrained aides to perform transfers and incontinence care alone, contrary to the facility assessment, policies, and care plans. Timecard review showed that on 34 of 84 shifts between early January and mid-February, only one direct care staff member was on duty, despite the facility assessment requiring at least two direct care staff and one nurse per shift when residents required mechanical lifts or two-person transfers. The AIT and ADON both acknowledged ongoing staffing shortages, frequent no-shows, and that resident care suffered because the facility was short staffed. The AIT stated it was not safe to have only one aide working on the floor and that policies requiring two staff for transfers and incontinent care were not always followed. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff and a mechanical lift for transfers was dropped during a mechanical lift transfer performed by a single aide who was not certified and had no documented training or abuse/neglect education. The resident reported being dropped to the floor, then pulled back into the wheelchair and told not to report the fall; her roommate, who had moderate cognitive impairment, stated she saw the aide alone with the lift, heard the aide exclaim, and observed the resident and lift on the floor. The resident was later found dragging her leg, reported pain, and was hospitalized with a distal femur fracture requiring surgery. The aide later stated she had not been trained on mechanical lift use and denied transferring the resident alone, while another aide and a nurse gave conflicting accounts and denied assisting with the transfer. Another resident with severe cognitive impairment and a care plan requiring two-person mechanical lift transfers was observed being transferred by a single aide using a stand-and-pivot method without a mechanical lift. The aide admitted she was the only aide working, knew the resident required a mechanical lift and two staff, and stated she routinely transferred the resident this way because no help was available. A third resident, with moderate cognitive impairment and high fall risk, required prompt response to call lights and assistance with transfers and toileting. She activated her call light to request help to the restroom, but no staff were present in the hall or at the nurses’ station; after waiting, she attempted to go alone, urinated on herself, slipped, and was found on the floor by a hospice aide while the call light was still engaged. The AIT confirmed that only one aide was on duty that shift, that staff no-shows were common, and did not explain why she and the ADON, who were in the office, did not answer call lights. A fourth resident with moderate cognitive impairment, colon cancer, muscle weakness, and a high fall risk had multiple falls over several weeks, including two falls on the same day that resulted in rib fractures, pleural effusion, and hospitalization, and another fall causing a forehead injury. Progress notes documented repeated falls related to attempts to transfer or reach items independently, and the resident’s representative reported the resident was anxious and tried to get up on her own. The care plan for falls had not been updated with new interventions since several months prior, despite the series of falls. Timecards showed that during at least two of the resident’s falls, only one direct care staff member was on duty. A fifth resident with severe cognitive impairment, depression, anxiety, mixed bladder incontinence, and a care plan requiring staff assistance for toileting and checks/changes every two hours was left in wet clothing for approximately two hours after requesting help. She first asked the only aide on duty, who told her she was too busy. The resident was later observed crying in the hall and then sitting in the dining room with visibly wet pants. When she asked an RN to change her, the RN looked at her but did not acknowledge the request. The resident became upset and attempted to remove her wet clothes in the dining room, after which the ADON reprimanded her and told her to go to her room. She was not assisted with changing until about two hours after her initial request. The aide later stated she was working alone, was very busy, and acknowledged that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Personnel file reviews showed that aides designated as nurse aides were not certified and lacked documented training, including mechanical lift training and, in at least one case, abuse/neglect training. The facility’s policies required two staff for mechanical lift transfers and prohibited aides from performing transfers and incontinent care alone, and the facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The MD stated his expectation that residents be free from abuse and neglect, that policies be followed, and that residents’ needs be met by staff with the knowledge and skills to provide necessary care, and he confirmed that being dropped from a mechanical lift could cause the type of femur fracture sustained by one resident and that not following transfer policies could have led to injury for another resident. An Immediate Jeopardy situation was identified related to these failures.
Removal Plan
- Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; if there are any mechanical lift residents, ensure a total of one LVN/RN and two direct care staff are in the building at all times; assess staffing requirements weekly based on census and resident needs; maintain two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
- Ensure DON and ADON verify that all agency or temporary direct care staff have documented training/credentials prior to working a shift (including checking the agency portal and obtaining CNA credentials from the sister facility) and ongoing.
- Assess Residents #5, #3, #2, and #16 for any further injury, pain, or emotional distress.
- Report Resident #1's fall to the state agency per reporting requirements.
- Assess and monitor Resident #1 for negative outcomes.
- Remove NA-A from resident care pending investigation.
- Complete investigation of the incident by AIT.
- Terminate NA-A as disciplinary action.
- Create an informational handout for incident reporting and mechanical lift use and review it.
- Provide an instructional mechanical lift demonstration for all staff by the facility's COTA.
- Review incidents within the last 30 days to identify other residents at risk.
- Re-educate all direct care nursing staff on shift on abuse/neglect policy (including safe transfer procedures and supervision expectations) with a signature sheet; require review for all direct care staff before start of first shift.
- Provide abuse/neglect and related education at an in-service with a signature page.
- Ensure the agency and sister facility only send CNAs.
- Require the charge nurse to verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse/neglect during shift report prior to the aide starting the shift; require verbal return instruction to determine competency.
- Re-educate all residents about their rights, abuse, neglect, and reporting.
- Review abuse, neglect, transfers, and reporting upon hire; provide monthly review at mandatory in-service; provide one-on-one education annually at staff hire anniversary; enforce that any violations of policy will result in termination.
- Require the charge nurse to initial, date, and log the name of each agency and sister facility staff member educated.
- Complete a mandatory all-staff in-service reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect.
- Reinforce expectation that violations of abuse/neglect, mechanical lift, and reporting policies will result in disciplinary action up to and including immediate termination.
- Train all staff on falls and call light usage via phone calls with return instruction to ensure retention of information; prevent staff who do not answer the phone from returning to work until retrained; maintain a DON log of staff contacted and educated.
- Have DON/designee review all incidents daily for 30 days to establish a risk-of-incident analysis based on patterns of staffing and incidents.
- Conduct a monthly abuse/neglect audit for direct care staff and incidents and report to QAPI for 3 months.
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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