Failure to Protect Residents from Resident-to-Resident Abuse: Multiple residents with cognitive impairment, dementia, schizophrenia, bipolar disorder, PTSD, and other behavioral diagnoses were involved in physical and verbal altercations. One resident with aphasia and dementia was punched in the jaw by another resident after a confrontation on the patio, and another resident was punched in the arm during a dining room incident that also involved a third resident pushing the aggressor away. A separate event involved a resident with severe cognitive impairment standing over a roommate in bed and hitting him, resulting in a bruise and skin tear. Staff described limited observation in the dining area and the facility’s investigations were documented as inconclusive.
Resident verbally abused by staff member: A cognitively intact resident with multiple chronic conditions reported that an LPN bullied, yelled, and cursed at him and threw him to the floor, leaving him scared. Multiple CNAs and residents described hearing the LPN use disrespectful language, including racial slurs, and seeing the resident pushed back into his room and later found on the floor crying. The DON stated APS later notified the facility of an allegation of physical and verbal abuse by the same LPN.
Failure to Report and Investigate Abuse Allegations: The DON, ADON, and Administrator did not treat a resident’s reported fight with a CNA and a separate resident-to-resident assault as reportable abuse events. Records showed conflicting resident statements, visible injuries, and staff accounts describing physical aggression, yet the incidents were not promptly reported to State agencies under the facility’s abuse policy. The Administrator stated the events were not considered abuse because of the residents’ statements and lack of willful intent.
Failure to Timely Report Suspected Abuse Allegations: The facility did not timely report suspected abuse involving a resident and CNA, and did not report a resident-to-resident altercation until the state agency brought it to its attention. Records showed one resident with mood disorder, SI, anxiety, and depression reported a physical fight with a CNA and had scratches, while two other residents were involved in an incident where one resident was found over the other and the injured resident had a bruise and skin tear. Staff and the DON discussed the events internally, but the administrator determined one allegation was not reportable and the other was not abuse, despite policy requiring immediate reporting of suspected abuse.
A resident with moderate cognitive impairment and multiple chronic conditions was involved in a transfer when staff observed her stiffening and slipping from her wheelchair. During the assist, an LPN was reported to have hit, smacked, or jabbed the resident’s leg while telling her to relax and bend her knees. The resident later said the nurse hit her leg, a roommate heard yelling, and written statements described the resident as crying and reporting that she had been struck during care.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
A resident with multiple chronic conditions and moderate cognitive impairment was involved in an incident during a transfer when an LPN tapped or hit her leg while staff tried to reposition her. The resident’s family later reported that the nurse had struck her legs, and staff interviews confirmed the allegation was not reported immediately as required. The facility’s abuse policy required reporting within two hours, but the allegation was not escalated until the next morning.
Incomplete Investigation of Alleged Staff-to-Resident Abuse: A resident with moderate cognitive impairment and multiple medical conditions was involved in an alleged abuse incident during a transfer when staff observed her rigid and slipping from her wheelchair. Accounts differed, but witness statements and the resident’s report described an LPN hitting or smacking the resident’s legs while telling her to relax, and bruising was documented on the knees. The facility’s investigation was not thorough because it left out relevant written witness statements and still concluded the allegation was unsubstantiated.
A resident with a history of behavioral issues and poor impulse control was transported in close proximity to another resident who had impaired communication and a history of physical aggression. A CNA moved both residents at the same time by holding one hand on each wheelchair, and the residents were positioned very close together when one resident struck the other three times on the chest. The assaulted resident later described the same event, and nursing staff documented that the incident was reported and assessed afterward.
A resident with Type 1 DM had ordered scheduled and sliding-scale insulin, along with instructions to notify the MD for blood glucose readings below 65 mg/dL or above 400 mg/dL. The MAR showed elevated blood glucose results that met the notification threshold, but there was no documentation that the provider was notified. The record also showed a missed scheduled insulin dose and a missed sliding-scale dose, with no documentation explaining why the insulin was not administered. Interviews with the CNA, RN, LPN, and DON confirmed the importance of following physician orders, documenting blood glucose results, and notifying the provider for abnormal readings.
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