A facility failed to protect two cognitively impaired residents from inappropriate sexual behavior. One resident was severely cognitively impaired with dementia-related behaviors, and the other had moderately impaired cognition with diagnoses including dementia, anxiety, and other sexual disorders. Staff observed repeated kissing, holding hands, mutual touching, and fondling between the two residents, while the DON and Administrator treated the relationship as consensual based on body language and apparent enjoyment, without requesting capacity evaluations despite policy stating sexual contact with a resident lacking capacity to consent is abuse.
A resident with cancer and dementia was repeatedly kept out of bed, redirected away from sleep, and kept in a wheelchair or recliner by an LPN who said the resident was a fall risk. Staff reported the LPN removed the resident’s room name plate, unplugged the resident’s personal phone, and declined help from others who tried to put the resident to bed. The resident was heard asking to go to bed, asking where the room was, and saying they did not have a place to sleep.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
Missed insulin administration to multiple residents: A nurse failed to give ordered insulin to several residents during a medication pass, and the MAR/EHR showed the doses were not completed. Residents with diabetes and varying cognitive impairment had scheduled and sliding-scale insulin left unsigned, including one resident whose blood sugars remained HI and another whose insulin doses were omitted without any progress note explaining why. CMAs reminded the nurse, but the insulin still was not administered as ordered.
A resident with severe cognitive impairment, nonverbal communication, and wheelchair dependence was found in a sexual situation with another resident who also had severe cognitive impairment. Staff discovered the other resident with his penis in the resident’s hand in a common area, and the resident could not meaningfully consent or provide a statement. The facility had policies requiring protection from resident-to-resident abuse and ongoing assessment of consent, but the contact occurred before staff intervened.
Failure to Protect Residents from Abuse: A CNA/CMA was witnessed yelling at and physically restraining a resident during shower care after the resident resisted, including grabbing the resident’s wrists and pushing her hands to her chest while the resident cried out that it hurt. Two other residents with behavioral concerns were also involved in separate incidents where the same staff member was reported to have grabbed a resident after being hit and scolded another resident over a recliner issue, with one resident describing the interaction as verbal abuse. The facility did not timely report the abuse allegation to DIAL or law enforcement for the incidents described.
Failure to protect a resident from resident-to-resident aggression: one resident with moderate cognitive impairment threw a package of wipes at his roommate after becoming annoyed by singing, striking the roommate in the chest. The roommate, who had legal blindness and intact cognition, reported chest pain for 2 days and received Tylenol with relief; no visible injury was noted on assessment.
A resident with intact cognition and dependence for transfers was bruised during rolling and bed mobility when staff reportedly held his arms too hard, with deep purple bruises documented on the wrist/hand and elbow and photos showing finger-mark-like lines. The record also included repeated concerns about rude or intimidating staff interactions, incomplete abuse investigations, and delayed ADL and incontinence care for other residents.
Staff used personal cell phones to take and share resident-related images and video without consent. A CNA admitted taking a Snapchat photo of a severely cognitively impaired resident’s soiled brief and thighs, and another CNA admitted sending a Snapchat video of a male resident urinating in a trash can to other CNAs. Interviews showed staff knew photos and videos of residents were not allowed, even when faces were not visible.
A resident with dementia and independent transfer status was physically forced by a CNA during an attempted transfer to supper after she said no. Witnesses reported the CNA grabbed both arms, pulled on the resident’s forearms, and tried to lift her into a wheelchair without a gait belt, while the resident resisted and later reported pain. The resident was found with two new bruises on the forearm, and multiple staff described the CNA as rough, rushed, and inappropriate with residents.
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