Failure to Protect Resident from Sexual Abuse: A cognitively intact resident reported that another resident approached her from behind in the dining room, made a sexual comment, and touched her breast. The other resident later admitted the contact. Records showed he had a history of sexually inappropriate comments and wandering into other residents’ rooms, and he had a care plan for sexual inappropriateness with redirection and monitoring interventions.
A resident with severe dementia and aggressive behaviors struck another resident in the face with a closed fist after the second resident returned to the dining room and tried to take food from the first resident’s plate. Both residents had severe cognitive impairment and histories of physical and verbal aggression, and the victim’s care plan noted food insecurity and the need to offer snacks or an alternate plate when others were eating. Staff separated the residents after the assault, and the victim later could not recall who hit him.
Failure to protect residents from abuse: one resident made explicit threats of bodily harm toward another resident, causing fear and emotional distress, and the same resident later sexually touched a female resident by reaching inside her shirt and contacting her breast. Records showed a history of intoxication, aggression, boundary issues, and inappropriate sexual behaviors, with inconsistent behavior monitoring documented by staff.
Failure to Protect Residents from Sexual and Physical Abuse: The facility did not keep residents free from abuse when one resident grabbed a female resident’s breast, another resident kissed a female resident on the lips twice despite her objection, and a third resident intentionally ran over another resident’s toes with a wheelchair. The involved residents had significant medical and cognitive issues, including dementia, cognitive impairment, paralysis, and behavioral histories, and the report states the facility’s abuse protections and behavior interventions were not effective in preventing these resident-to-resident incidents.
Failure to Protect a Resident from Physical Abuse by Another Resident: A resident with dementia and agitation was physically assaulted by another resident after a verbal dispute over missing property. The altercation escalated when one resident pushed the other in the chest, causing both to fall, and the victim later reported severe pain and was sent to the hospital with a chest wall contusion. Facility records and interviews confirmed the abuse occurred.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: A resident with dementia and poor impulse control threw water on one resident and then pushed another resident when confronted, causing the second resident to fall. The first resident was found wet with no injury, while the second resident had no visible injury at the time but later reported mild pain. Records showed the aggressor had prior peer altercations, and facility leadership confirmed that pushing or throwing water on another resident was abuse.
Failure to protect a resident from resident-to-resident physical abuse occurred when one cognitively intact resident struck another resident in the face after being told not to enter the room. The injured resident had a swollen cheek, facial pain, and bruising under the eye, while the other resident had a documented history of wandering into peers’ rooms, seeking cigarettes, and taking items. The behavior care plan did not include interventions for that specific pattern of room entry and theft-related behavior, and the incident was not substantiated despite the physical injury.
Sexual Abuse by Housekeeper: A resident with dementia and moderate cognitive impairment was sexually abused by a housekeeper after their interactions had progressed from conversation to hugging and kissing. A facility employee witnessed the housekeeper wait for the resident in the salon, hug her, and kiss her on the neck and lips while the resident responded with affection and attempted to hug him. The investigation substantiated sexual abuse, and the resident could not recall the event when later assessed.
A resident with a history of CVA-related hemiplegia, TBI, and anxiety reported that an LPN got in her face and yelled at her over scheduled pain medication, leaving her fearful and upset. A grievance documented the resident crying and requesting that the LPN no longer be assigned to her, but the LPN continued to provide care and administer meds for months afterward, with no documented psych-social follow-up after the incident.
Failure to Protect a Resident from Sexual Abuse: A resident with intact cognition and multiple chronic conditions was sexually abused by another resident in the dining room when he touched her breast over her clothing after summoning her to his table. The event was substantiated by video and witness statements, but the victim’s record showed no added care plan interventions, no progress notes, and no documented monitoring for changes from baseline. The other resident had dementia and a known history of inappropriate touching, with existing interventions that were not effective in preventing the incident.
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