Failure to protect a resident from sexual abuse by another resident. A resident with severe cognitive impairment and depression was involved in two separate incidents with another resident who had documented hypersexual behavior, impaired cognition, and conflict with female residents. Staff witnessed one incident in which he attempted to get her to open her mouth so he could insert his penis, and another in which he exposed his penis to her; both allegations were substantiated.
A resident-to-resident altercation occurred when one resident repeatedly entered a shared bathroom and then pushed another resident, causing the resident to fall backward to the floor. Staff observed the fall, heard the resident say she had been pushed, and documented the aggressor as aggressive, verbally abusive, and difficult to redirect. The involved residents had significant psychiatric and cognitive diagnoses, and one resident’s care plan noted behavior issues involving the shared restroom.
A resident with moderate cognitive impairment and extensive medical diagnoses was physically and verbally abused by a CNA during care. Video reviewed by family and facility leadership showed the CNA speaking derogatorily to the resident, and the resident reported that the CNA slapped her in the face. The sheriff’s office report documented the CNA striking the resident with the backside of his hand, and the resident later told the surveyor she felt alright and safe in the facility.
Failure to Protect a Resident from Sexual Abuse: A resident with moderate cognitive impairment and dependence for ADLs was kissed on the mouth by another resident while lying in bed. Staff observed the interaction, removed the other resident, and the resident stated the contact was unwanted and non-consensual and that she could not express no. The other resident admitted to the kissing and minimized the behavior despite knowing the resident could not consent.
Residents reported that a CNA used a loud, rude, and mean tone, refused requested care, and handled them roughly during ADL care. One resident said the CNA yelled at her and would not change her wet pants, another said the CNA yanked her gown, pulled her shoulder, and wiped her hard causing pain, and a third said the CNA pulled her leg hard and would not stop when told it hurt. Staff and police interviews also reflected concerns about the CNA’s conduct, including reports of rough and rushed care and failure to provide needed assistance.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Failure to protect residents from abuse occurred when one resident with severe cognitive impairment repeatedly assaulted multiple residents, causing scratches, a skin tear, broken glasses, and other injuries, while another resident with dementia and intermittent explosive disorder hit a resident during an agitation-related incident. Facility investigations substantiated the abuse events, but the record showed no documented ongoing monitoring, supervision, or care plan changes for the abusive residents after the incidents.
A resident with schizophrenia, severe cognitive impairment, traumatic brain injury, and documented aggressive behaviors physically assaulted another severely cognitively impaired resident who had no documented behavioral issues. The aggressive resident’s care plan identified risk for behavior problems and called for monitoring and behavioral interventions, yet he was able to engage in an altercation in which the other resident was found on the floor with the aggressor standing over him, flailing his arms. The injured resident sustained a scalp laceration and rib contusion. The DON reported there had been a previous incident between the same two residents and acknowledged not initially recognizing the severity of that earlier event, and the aggressive resident was not placed on 1:1 supervision but only on behavioral monitoring.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A resident with Parkinson's disease and limited mobility was not protected from another resident with dementia and a history of physical and verbal aggression. The roommate threw food and a tray at her, threatened to kill her, and staff interviews confirmed prior aggressive behavior and threats toward other residents. The resident stated she felt unsafe and feared being attacked, while staff acknowledged the roommate's behavior and the impact on the resident.
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