A cognitively impaired resident with dementia and no decision-making capacity was sexually abused by another resident after multiple staff members observed the interaction but did not immediately intervene or separate the residents. A PTA, a GNA, and a maintenance assistant each saw the residents engaged in sexual activity or in a sexual position, yet staff exited the room, closed the curtain or door, or delayed reporting the event instead of stopping it right away.
An LPN was alleged to have physically abused a resident by taking the resident’s reacher aid and hitting the resident with it during an argument about requested eye drops. The resident confirmed the incident, while the LPN denied abuse but admitted taking the reacher aid and accidentally striking the resident on the arm. The DON later confirmed the LPN’s response was inappropriate.
A resident with hoarding behavior and generalized anxiety disorder was involved in a confrontation with the NHA during a room cleanout after staff began discarding spoiled food. The NHA and resident struggled over a bag of food, the bag tore, and the resident later reported bruises on both wrists from the altercation. Multiple staff witnessed the event, but the allegation of abuse was not immediately reported because staff believed it had already been observed and did not think abuse occurred.
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.
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