Physical abuse of a resident with severe cognitive impairment, trach, and ventilator dependence occurred when a respiratory therapist was captured on hidden-camera video pushing the resident’s hand down, throwing a towel on the resident’s face, pulling and twisting the resident’s hands, hitting the resident on the face and head, and forcibly holding the resident down. The resident later had ED findings of contusions and a subdural hematoma, and the facility’s investigation determined the staff member’s actions were not consistent with policy.
A resident with cognitive impairment, altered mental status, and ADL assistance needs was verbally abused by staff during care. A family recording and staff statements supported that the resident resisted care, care continued anyway, and a CNA made inappropriate comments; the facility’s investigation concluded the incident was verbal abuse/inappropriate language.
A resident who spoke only Arabic and had no cognitive deficits did not receive assigned personal care for an entire day shift when the CNA avoided the resident after perceiving the family as rude and did not notify a supervisor. The resident’s care plan required use of a translator phone for communication when family was absent, and EMR review showed the CNA did not document any care for that shift, although nurses entered for medications and the resident received meals. Another CNA reported the lack of care and provided personal care late in the shift, and the resident’s family confirmed that the regular CNA did not come in to see the resident during that period.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A resident with CHF, atrial fibrillation, and hypertension developed loose, foul-smelling dark stools and acute hypotension, with BPs in the 70s/40s and later in the 60s/30s, while on 2 L/min O2. Nursing staff notified an ADON, who obtained orders for STAT labs, X-ray, and urinalysis and told staff they were waiting on the physician, despite a telephone/verbal order from the physician to immediately call 911 and transfer the resident to the ER for a change in condition and low BP. The physician arrived later that morning expecting the resident to have been transferred, learned from an LPN that the resident was still in the building and more hypotensive, and again ordered immediate ER transfer, at which point 911 was called. Documentation and interviews revealed discrepancies between the ADON’s late-entry notes, the order audit report, and staff accounts, as well as lack of timely notification to the DON and a minimal, nonspecific internal investigation summary. The resident was ultimately transported to the ER, admitted with shock, anemia, and hyperkalemia, and expired the same day.
A cognitively impaired resident with a history of depression, anxiety, and severe cognitive impairment told a CNA that a night-shift CNA had punched them in the ribs. The CNA reported the allegation only to an LPN, who allegedly said he did not want to get involved, and the CNA did not escalate the report further, leaving the allegation undocumented in the record. When later interviewed, the resident stated they had received a couple of punches from a staff member and that the CNA knew who it was. Other staff described the resident as confused but not prone to false accusations. Facility leadership stated that all abuse allegations must be immediately reported up the chain of command for investigation and that accused staff should be removed from duty, but they were unaware of this allegation until informed by surveyors, indicating the facility’s abuse reporting policy was not followed.
Failure to Protect Resident from Abuse: An alert and oriented resident reported that an LPN yelled at them, got in their face, poked at their face, and stomped on their foot after a dispute over PRN medication. Another resident partially corroborated the account, while facility leaders treated the event as a grievance rather than an abuse allegation and did not report it as abuse.
A severely cognitively impaired resident with dementia refused medication, and an LPN continued attempts to administer it. When the resident threw juice, the LPN pushed the resident’s wheelchair forward toward another chair, then grabbed the resident’s arm and roughly pushed the resident into another wheelchair, as confirmed by video. An activity aide witnessed the event but did not immediately report it to the DON or nursing supervisor, instead leaving a written statement that was not promptly found. A subsequent skin assessment showed no injuries, and the facility’s investigation substantiated the abuse allegation.
Failure to Protect Resident from Physical Abuse: A cognitively intact resident with COPD reported that an assigned CNA grabbed her arm and forcefully removed her dress while she was trying to find her cell phone before bedtime care. The roommate and RN later reported the resident was emotional and said the CNA hurt her, and the DON stated the facility substantiated staff-to-resident abuse.
Failure to protect a resident from resident-to-resident abuse occurred when one cognitively impaired resident struck another resident after a brief interaction at the nurses’ station. The assaulted resident sustained a swollen lip and lost two front teeth, while staff interviews and the incident investigation noted neither resident had prior behavior concerns before the event.
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