F0600

D

Failure to Protect Two Residents From Physical and Verbal Abuse by Nursing Assistant

Wyncote, Pennsylvania Survey Completed on 04-14-2026

Penalty

No penalty information released

Summary

The facility failed to ensure residents were free from abuse when two residents reported being physically and verbally mistreated by a nursing assistant during care. One resident with dementia but a BIMS score indicating intact cognition reported that on a late evening, two staff members, described as a male and a heavy-set female nursing assistant, attempted to change the resident despite the resident’s refusal. The resident stated that the staff turned the resident violently, that the male staff member hit the resident after a possible altercation, and that both staff and resident were swearing during the incident. The resident identified the female nursing assistant as the person who had provided care that night and later identified the male nursing assistant through the nursing supervisor. The facility’s investigation documentation indicated that the allegation against the female nursing assistant was substantiated, while the male nursing assistant was determined by the facility not to be involved.

A second resident with a history of cerebral infarction and a BIMS score indicating moderate cognitive impairment reported that the same female nursing assistant slapped the resident’s wrist three times and then grabbed the resident’s glasses. The resident’s statement and demonstration of the incident were documented in the facility’s investigation, which concluded there was sufficient concern regarding inappropriate physical interaction. The facility’s report to the State Survey Agency documented that the allegation against the female nursing assistant was substantiated and that the allegation was considered substantiated in the facility’s reported incident. The nursing home administrator confirmed these findings during interview.

Plan Of Correction

1. A thorough investigation of allegations of abuse was conducted for Resident R1 and R2. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R2. Employee E3, nurse aide, was terminated based on multiple allegations and refusal to provide statement. Employee E4, nurse aide was found to be not involved with Resident R1 based on facility investigation.

2. Facility will ensure that there will be strictly zero tolerance for any resident abuse and neglect. Any allegations of abuse or neglect will be thoroughly investigated. Appropriate corrective action plans will be taken such as disciplinary action/terminations.

3. All staff will be reeducated on abuse/neglect policy and procedures as part of the facility's mandatory abuse and neglect training. All new hires will also be educated on topics of abuse/neglect policy and procedures as part of facility's orientation.

4. The Administrator/Designee will monitor the frequency and pattern of all abuse allegations and follow up investigations. Any areas of non-compliance will be addressed in QAPI for two quarters or until substantial compliance is met.