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.
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.
Failure to Protect Residents from Repeated Verbal Abuse: A resident with schizophrenia and another resident with severe cognitive impairment were repeatedly verbally abused by a resident with known aggressive behaviors in the dining room. The first resident became fearful, avoided the dining room, and had sleep and participation changes, while the second resident became tearful after being called names and mocked. Surveyors found the abusive resident’s care plan did not reflect the interventions tied to the repeated incidents, and the victims’ care plans did not document the abuse episodes.
Failure to Protect Residents from Abuse: The facility did not protect one resident from verbal abuse and two residents from physical abuse by other residents. One cognitively intact resident was upset and tearful after another resident made an inappropriate sexual comment about her dress. Another cognitively intact resident was grabbed by the wrist and hit in the face by a roommate after tapping his fingers during therapy exercises, with bruising noted. A third resident with moderate cognitive impairment was struck in the face by another resident during a conflict in line for the smoking area, and a cheek discoloration was documented.
Failure to Protect a Resident from Physical Abuse by Another Resident A cognitively intact resident who was dependent for most care was in bed when another resident with severe dementia and wandering behaviors entered her room, went through her belongings, and threw multiple items at her, including papers and Kleenex. The resident reported being hit in the head and lower back, later complained of headache and head pain, and said the incident made her nervous and vulnerable. Staff and the roommate confirmed the other resident was in the room throwing objects, and the record lacked a progress note documenting the incident in the resident’s EMR that day.
Failure to Prevent Resident-to-Resident Physical Abuse: Two residents were involved in a hallway altercation when one resident postured as if to hit the other, the second resident slapped the first resident's arm, and the first resident then struck the second resident in the back of the head with a closed fist. One resident had severe dementia with wandering and disruptive behaviors, while the other was cognitively intact but had a history of episodic physical aggression toward other residents.
Failure to Protect Residents from Physical Abuse: A resident with dementia, agitation, and a history of verbal and physical aggression was involved in multiple resident-to-resident altercations. In one event, two residents exchanged blows in a hallway after one yelled at the other to hit her, and the resident grabbed her neck/shoulder area to stop the strike. In another, the resident entered a peer’s room and pushed her. In a third, he struck another resident in the face with a closed fist while she was seated near the nurses’ station. Staff interviews and record review documented the residents’ behaviors and the physical contact involved.
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
Failure to Protect a Resident from Repeated Verbal Abuse: The facility failed to keep one resident free from repeated verbal abuse by another resident. Records and interviews showed a resident with schizoaffective disorder and moderate cognitive impairment repeatedly called another resident derogatory names in the dining room, causing emotional distress. The victimized resident had anxiety and depression and reported the behavior had continued over time, but the incident was not documented in the care plan or progress notes.
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