A resident admitted for rehab after joint replacement surgery and a knee prosthesis infection was verbally abused by a GNA after asking for ice. The resident reported profanity and rude comments, and a COTA and LPN both observed the interaction and the resident’s distress. The facility’s investigation documented the incident, but only a limited number of resident abuse interviews were completed, weekly audits were not produced, and QAPI minutes did not show discussion of the verbal abuse event.
Failure to Protect a Resident from Abuse: A resident with severe cognitive impairment sustained bruising and skin tears to the left arm during an interaction with a GNA. The GNA reported prying the resident’s hand from the arm after the resident grabbed the GNA, while the night supervisor later observed active bleeding and the resident stated, “The aide did this to me.” Two other residents described the GNA as rough and not gentle during care, and the GNA had a prior disciplinary action for being heavy-handed with residents.
Verbal Abuse Toward a Resident: A GNA entered a resident’s room after a complaint about care and confronted the resident about getting the staff member in trouble. The resident reported feeling threatened and intimidated, and a roommate heard the staff member make angry comments in the hallway and then speak similarly to the resident in the room. The facility substantiated the allegation as intimidation and verbal/mental abuse.
Failure to Protect Resident from Verbal Abuse: A resident and an LPN had a heated verbal altercation after the resident came out of the room upset that requested ADL assistance had not been provided. The resident stated the LPN loudly used obscenities, while staff accounts confirmed a verbal exchange with obscenities between the resident and the LPN. Social Services and unit leadership intervened, and the incident was later reviewed as an alleged abuse event.
A facility failed to protect residents from abuse and intimidation. One resident with a history of sexually inappropriate and aggressive behaviors was allowed to remain in contact with others despite repeated incidents of inappropriate touching, threats, and verbal altercations, and another resident reported being touched in private areas. The facility also did not fully investigate an allegation that an aide had been taught to hit a resident or suspend the staff involved pending the investigation. In a separate incident, a GNA threatened a resident during med pass, grabbed the resident’s hand, and moved a fist toward the resident’s face, leaving the resident scared and feeling unsafe.
Failure to protect a resident from abuse occurred when staff observed one resident in another resident’s room with pants pulled down and genitals exposed while the other resident was in bed, and another staff member reported the resident rubbing the other resident’s stomach under a blanket. The affected resident had dementia with a BIMS score of 0 and could not describe the incident. Records showed the other resident had prior concerns for sexually inappropriate behavior and room-entry issues, but no documented supervision or behavior interventions were in place before the event.
Verbal and Mental Abuse of a Resident: A GNA entered a resident’s room yelling and threatened to have a family member come to the facility to "take care" of the resident. The resident, who had quadriplegia, chronic pain syndrome, anxiety, depression, neurogenic bowel, opioid dependence, and generalized weakness, confirmed the incident, and the facility’s investigation substantiated a verbal altercation based on resident, witness, and staff statements.
A cognitively intact resident with severely impaired vision and a need for help with transfers and toileting was verbally abused by a CNA during toileting care. Staff overheard the CNA shouting, using foul language, and slamming the bathroom door while the resident called for help. The resident later reported being told, "F you," and said the incident left him/her tearful, anxious, and concerned about safety.
Failure to Prevent Verbal Abuse by Staff: Two cognitively intact residents were verbally abused by staff during care and activities. One resident recovering from joint replacement surgery reported a GNA responded in a demeaning, aggressive way during incontinent care, while another resident said an Activities Director yelled and was mean after a request for a word search; a witness confirmed the resident was in tears.
A resident was subjected to verbal abuse when a staff member used abusive language while attempting to bring the resident inside from a smoking area. Witnesses reported that the staff member told the resident to come inside, sit down, and shut up, and the staff member later confirmed having a verbal exchange with the resident and telling the resident to shut up. The facility’s internal investigation verified that this interaction constituted verbal abuse.
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