A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with dementia, schizoaffective disorder, and a history of verbal and physical aggression was involved in a care encounter with two CNAs when he struck one CNA and the other blocked him. During the interaction, the second CNA used insulting and profane language toward the resident, including calling him a “sissy” and “fucking pussy,” while staff later described the exchange as de-escalation and the facility concluded the abuse allegation was not verified.
Neglect Related to Hydration and Access to Fluids: A resident with severe cognitive impairment and multiple chronic conditions, including ESRD on dialysis, had no fluid restriction but was found with dry, chapped lips, no water pitcher or glass in the room, and a bedside table positioned out of reach. The resident stated she was thirsty and had to use the call light to request water, while the CNA POC showed several "not applicable" fluid entries on days the resident was not out of the facility and several days with low documented intake. Staff and the DON confirmed that water should be available in the room and that neglect includes failure to provide water and basic needs.
A resident with severe cognitive impairment and repeated aggressive behaviors was involved in a physical altercation with another resident who had intact cognition. The incident followed escalating verbal conflict, and one resident sustained bleeding injuries to the face and leg and was sent to the hospital. Staff interviews confirmed the event was treated as a resident-to-resident altercation, and the administrator acknowledged that one resident hitting another would normally be considered physical abuse, though he did not view this event as willful.
Failure to Protect Residents from Verbal Abuse: Two residents were involved in a dining room altercation after one resident repeatedly used derogatory language toward the other, despite being asked to stop. Staff and witness statements confirmed the exchange was angry and not joking, and the DON acknowledged the language met the definition of verbal abuse. One resident had behavioral issues related to impulsivity and attention seeking, while the other had severe dementia and Parkinsonism but was documented as cognitively intact on BIMS.
Two residents with cognitive impairment and behavioral issues were involved in a resident-to-resident altercation after one resident yelled profanity and racial slurs and the other resident confronted him, then ran into his room despite staff redirection. Staff later observed both residents slapping, pushing, swearing, and threatening each other before separating them. The incident occurred while one resident was waiting for assistance after dialysis and the other resident reacted to the verbal aggression.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Two cognitively intact residents became involved in a physical altercation in the activity room after one resident repeatedly bumped the other resident's wheelchair or leg. Witnesses and the residents reported hair pulling by both residents, with one resident reporting pain and a finger injury and the other reporting leg pain. Staff and the DON/ED identified the event as physical abuse, and the facility policy stated residents have the right to be free from abuse.
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.
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.
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