Failure to Protect Residents from Physical Abuse During Resident-to-Resident Altercations: Two residents were involved in a physical incident after one resident repeatedly backed a wheelchair into another resident and was struck in the head, with video review substantiating physical contact. A later elevator altercation involved the same cognitively impaired resident and another resident, with witnesses describing grabbing, swinging, and punching that resulted in bruising, skin tears, and a fall. Staff and management acknowledged the physical contact, and the record showed prior concerns about the resident’s impulsive and aggressive behavior.
Failure to Protect Residents from Abuse and Physical Aggression: An LPN verbally abused a resident during a medication dispute, raising her voice and threatening to mark all meds refused after the resident questioned the pill. The report also described multiple resident-to-resident assaults involving residents with cognitive impairment and behavioral diagnoses, including punches to the face and eye, with staff and resident statements confirming the incidents and the facility acknowledging that physical altercations occurred.
A facility failed to protect residents from resident-to-resident abuse. In one incident, a cognitively intact resident with psychotic disorders and another resident exchanged racial slurs, and the second resident struck the first resident in the face, leaving redness. In another incident, a resident with dementia and severe cognitive impairment entered another resident’s room and hit her in the leg with a fist and a comb; the injured resident reported the intruding resident entered her room almost daily, and the facility did not identify the event as abuse or add lasting interventions.
A resident with dementia and Parkinsonism reported that a male CNA sexually assaulted her during the night, and staff interviews, voicemail messages, and camera footage showed the CNA entering her room and remaining inside with the door closed. The resident was fearful and anxious afterward, did not want the CNA around her, and the police report identified the CNA as the suspect for sexual penetration. Another resident also said the CNA made her feel uncomfortable and did not want him to provide care.
Failure to Protect a Resident from Resident-to-Resident Abuse: A resident with a history of aggression and verbal abuse repeatedly backed his wheelchair into another resident in a hallway until the resident fell, causing a head laceration and a hip fracture that required surgery. Surveillance video and the facility’s investigation substantiated resident-to-resident abuse, and records showed the aggressive resident had prior abusive incidents and a behavior care plan without added supervision interventions.
Failure to Protect Resident from Staff Physical Mistreatment: A resident with stroke-related paralysis, contractures, dementia, and visual impairment reported that a female CNA slapped and scratched him after he used his call light for a brief change. Staff documented facial injuries including scratches, forehead redness/abrasion, and a bruise or discoloration on the nose, while the resident and family reported he felt scared and uncomfortable asking staff for help.
A resident with Parkinson’s disease and dementia, who had a documented history of wandering into other residents’ rooms and beds, was found in another resident’s bed with his genitals exposed while the female resident’s breast was exposed. The female resident had severe cognitive impairment and could not meaningfully participate in an interview. Staff observations, charting, and the facility’s investigation verified inappropriate sexual contact, and the DON and Administrator acknowledged there should have been interventions in place for the wandering behavior.
A resident with a BIMS score of 14/15 was involved in a shouting match with a nurse after the nurse was overheard making a threatening statement, including that she would "blow" him out and the resident reported she threatened to shoot him with a pistol. The resident said the interaction made him feel challenged and that he felt he had to prepare to defend himself. An LPN heard the altercation, intervened, sent the nurse home, and called the police.
Failure to Protect Resident from Verbal Abuse: A resident with dementia and depression, and moderately impaired cognition, reported that a housekeeper told him to clean his own bathroom after diarrhea and stool contamination. Interviews with the resident, CNA, housekeeper, and UM showed conflicting accounts, but confirmed that wipes were intended for the resident to clean the area and that the interaction was not consistent with resident dignity, respect, and appropriate staff conduct.
Resident-to-resident abuse occurred when one resident wheeled to another resident’s side of the room, blocked the bathroom entrance, and pulled the other resident’s hair while shouting at her. The injured resident, who was cognitively intact and had multiple chronic conditions, reported severe pain, and staff interviews confirmed the incident and that the NHA later substantiated the event as abuse.
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