F0600

D

Failure to Protect a Cognitively Impaired Resident From Physical Abuse and to Investigate Abuse Allegation

Bronx, New York Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse and to respond appropriately to an abuse allegation. The facility had an Abuse Prohibition Policy and Protocol dated 09/11/2025 stating residents would be protected from abuse, neglect, and mistreatment, and that the facility had zero tolerance for any kind of abuse. Resident #1 had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, with a quarterly MDS dated 01/02/2026 documenting severely impaired cognition and a need for partial/moderate assistance with functional abilities. Care plans documented that Resident #1 wandered into other residents’ rooms uninvited, placing the resident at risk for potential abuse, and that staff were to monitor the resident’s whereabouts and redirect as needed, as well as address the resident in a calm and gentle manner; however, there was no documented evidence of the frequency of monitoring.

On 02/17/2026, surveillance video footage from approximately 4:34 PM showed Resident #1 getting up from a wheelchair and ambulating with an unsteady gait up the hallway while holding onto handrails. Resident #1 moved a cart stocked with personal protective equipment and rolled it into two residents’ rooms. Certified Nursing Assistant (CNA) #1, who was wheeling another resident up the hallway, stopped and went into one of the rooms behind Resident #1. The video showed CNA #1 rolling the cart back into the hallway, then standing in the doorway pulling Resident #1 by the arm and pulling the resident into the hallway. CNA #1 then held Resident #1 under the left armpit and pulled the resident up the hallway toward the wheelchair while Resident #1 continued to resist. CNA #1 placed Resident #1 on the edge of the wheelchair; as Resident #1 resisted sitting, CNA #1 held the resident under the left armpit, put a hand behind the resident holding them by the pants, and dragged Resident #1 back into the wheelchair, then pushed and held the resident’s upper body forward with one hand while the other hand moved back and forth at the resident’s lower back, with Resident #1’s body jerking forward. A visitor for Resident #2 was observed standing in a doorway looking in the direction of CNA #1 and Resident #1, and the visitor and CNA #1 appeared to be exchanging words and hand gestures.

Later that day, Resident #2’s visitor reported to the Director of Nursing (DON) that they observed CNA #1 being rough handed and hitting Resident #1 on the buttocks. The facility’s Summary Investigation for the incident documented that the visitor went to the DON’s office demanding discipline for CNA #1, describing a verbal altercation and stating they heard a commotion and came out to see what was happening, then asked CNA #1 what they were doing with Resident #1. The DON and Assistant Administrator reported that they reviewed the surveillance video to see the interaction between CNA #1 and the visitor and stated they did not identify CNA #1’s actions as abusive or excessively rough, characterizing the transfer as an attempt to maintain safety. The DON instructed a Registered Nurse Supervisor to assess Resident #1; the RN Supervisor reported observing Resident #1 smiling, in good spirits, with no visible injury and no complaints of pain or discomfort, but did not document this assessment in the chart or notify the physician. Despite the visitor’s report that CNA #1 was rough handed and hit the resident, and the video evidence of forceful handling while the resident resisted, there was no documented evidence that the allegation of abuse was investigated as abuse or reported to the New York State Department of Health, constituting a failure to ensure the resident was free from physical abuse and that an abuse allegation was properly investigated and reported.