Failure to Protect a Resident from Physical Assault: A resident with moderate cognitive impairment was punched multiple times in the face and head by another resident with severe cognitive impairment and psychiatric diagnoses while in a lounge area. The assaulted resident sustained a facial injury, oral laceration, loose tooth, and closed head injury requiring hospital evaluation, and staff interviews confirmed the assault occurred before the residents were separated.
Failure to Protect Residents from Verbal Abuse: Two cognitively intact residents who needed assistance with personal care reported repeated inappropriate comments from an NA during hygiene and incontinence care. One resident described body-shaming remarks about a "big a**" and avoided asking the NA for help afterward; the other reported sexualized comments, unwanted staring through a bathroom door, and threatening remarks that made him/her feel uncomfortable and ashamed.
Failure to prevent resident-to-resident abuse: Two residents with behavioral and psychiatric histories became involved in a dining room altercation after one confronted the other about a prior issue. Accounts of the event conflicted, including reports of a cane being swung, a push, and punches, while no staff directly witnessed the incident and the residents were only separated after staff arrived. The facility did not obtain detailed contemporaneous statements from either resident at the time of the event.
A resident with Parkinson’s disease, limited mobility, and extensive ADL needs was left on a commode by two NAs without the call bell in reach. One NA forgot to return for the resident, and the resident later tried to stand to reach the bell, fell to the floor, and was found by the overnight aide with a head bump and arm pain.
Failure to Protect a Resident from Inappropriate Sexual Contact: A resident with intact cognition entered another resident's room and touched the resident inappropriately after being admitted without the required sexual offender screening. Nursing notes, the RE form, and staff interviews showed the resident was self-propelling throughout the facility, was seen near the other resident's doorway, and was later removed after the allegation was reported to the provider and police.
Failure to protect residents from resident-to-resident physical abuse. One resident with COPD, anxiety, and PTSD was pinched multiple times by another resident with dementia and a known history of pinching while the assigned NA was charting and not maintaining eyes-on supervision. In a separate incident, a resident with hepatic encephalopathy and respiratory failure was grabbed by the neck of a gown from behind by another resident with Alzheimer’s disease, causing red marks on the neck and a report that the resident had been choked.
Failure to Protect Residents from Physical and Sexual Abuse: One resident with dementia-related behavioral issues struck another resident in the face during a group activity after a confrontation over another resident’s blanket, and a separate resident with severe cognitive impairment was observed fondling another resident in a hallway. Both incidents were witnessed or documented by staff, and the affected residents had significant cognitive or psychiatric diagnoses noted in their records.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse: A non-verbal resident with severe cognitive impairment and dependence for ADLs was found with blood in the brief after another resident was observed exiting the room wearing only underwear. Staff documented that the other resident could not explain being in the room, and later police forensic testing confirmed that resident's DNA on the victim's oral and genital swabs.
A facility failed to ensure timely medication administration when a charge nurse arrived late for the shift and no other nurse was assigned to start the med pass, obtain FSBS, or give insulin. Four residents had missed or delayed ordered meds and treatments, including diabetes meds, insulin, potassium, protein supplement, pain medication, and other scheduled therapies, with MAR entries showing doses as unavailable, refused, or held and incomplete nursing documentation for some omissions.
Neglect on the overnight shift involved delayed call-bell response, missed toileting and incontinent care, and failure to complete required rounds for two residents with ADL deficits and significant medical needs. One resident with C. Diff, AKI, and bowel incontinence reported using the bedside commode independently because staff did not answer the call bell or empty it, while another resident with CHF, CKD IV, a foley catheter, and oxygen therapy reported long waits for help and missed safety checks. Staff interviews described NAs turning off call bells, not responding, not doing 2-hour rounds, and leaving residents incontinent and linens soiled.
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