A CNA yelled profanity at a cognitively intact resident, grabbed the resident by the shirt/chest area, and pushed the resident to the floor after the resident became upset about being restricted from smoking. The resident reported being almost choked and hitting his/her head on the door, while a witness CNA saw the CNA push the resident against the door and then fall to the floor. The CNA admitted losing control and pushing the resident.
A resident with moderate cognitive impairment, depression, and one-sided weakness was allegedly abused during a shower when a CNA covered and twisted the resident’s mouth while the resident was crying. The resident later reported the incident to the DON, and the facility documented bruising to the mouth area with photos and observation findings. The investigation was substantiated, while another CNA heard the resident crying but did not assist or notify the nurse.
A resident with major cardiac and respiratory diagnoses was not properly monitored after admission, including missed VS checks and failure to follow a midodrine order requiring BP checks before administration. Staff did not document or escalate repeated complaints of chest pressure, did not notify the POA, and the resident’s code status was not accurately reflected in the chart; CPR was started when the resident was found unresponsive despite the POA stating the resident was DNR.
Resident-to-resident abuse occurred during smoking episodes when one resident struck another in the face after a cigarette-related confrontation, causing a facial laceration requiring sutures, and another resident kicked a peer in the head, causing bleeding and a scalp laceration requiring staples. The involved residents had significant psychiatric, cognitive, and behavioral histories, and facility interviews and records substantiated both events as physical abuse.
A resident-to-resident altercation occurred when one resident approached another during a movie and snack activity and threw hot coffee on the other resident, causing redness, pain, and burning to the face and chest. The assaulted resident then struck back, and the incident was later substantiated as abuse by the Administrator and DON. The involved residents had significant psychiatric diagnoses, and one resident was noted to have auditory hallucinations instructing harm toward the other resident.
Resident-to-resident altercation with jaw/neck grabbing and injury. Two residents became stuck while passing in a hallway, and after one resident made contact with the other’s arm, the second resident grabbed the first resident’s jaw/neck area and shook the resident. Staff documented discoloration and bruising to the resident’s upper neck/jaw area, and witness accounts described the grip as tight and choking/grabbing in nature.
Failure to Protect Residents from Abuse: A resident with cognitive impairment repeatedly engaged in inappropriate touching and kissing of two other residents, both of whom were severely cognitively impaired. Staff and witnesses reported contact with a resident’s arm, shoulder, knee, breast, inner thigh, crotch, and chest, as well as kissing another resident on the lips and causing that resident to cry. The facility’s abuse policy defined such conduct as abuse, but the incidents were treated as impulsive behavior and as residents seeking each other out.
Failure to prevent resident-to-resident physical abuse led to injuries in two separate altercations. In one event, two residents argued in the dining room, then one scratched the other’s neck and was hit in the face, leaving scratches, redness, and swelling. In another event, a resident pushed another resident’s plate to the floor, the other resident struck back with a reacher, and the first resident dug fingernails into the other resident’s hand, causing cuts. Both incidents involved residents with significant cognitive, psychiatric, and neurologic diagnoses.
A resident with multiple psychiatric and behavioral diagnoses was physically assaulted by another resident after a verbal dispute in a common area. Staff statements and the facility investigation described the other resident yelling, striking the resident in the face multiple times, and causing black eyes, scratches, and abrasions that required hospital evaluation. The other resident also had a history of aggressive behavior and medication refusal, and the incident was substantiated as resident-to-resident physical aggression with injury.
A resident with dementia and severe cognitive impairment struck another resident in the face with a fist after the other resident approached in close proximity at the nurse’s station. Staff heard the altercation, observed the injured resident holding the face with redness and later bruising, and the incident was documented as resident-to-resident aggression. Facility leadership and the psychiatrist NP did not consider the event abuse, describing it as an unintentional reaction related to the aggressor’s cognitive impairment.
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