Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
A resident with severe cognitive impairment and dementia-related diagnoses became combative during care and struck a CNA, after which the CNA struck the resident in the face. Witness statements and the facility’s investigation documented that care continued despite the altercation, the resident was not reapproached or redirected, and the resident had a bloody nose. The DON stated staff were expected to use de-escalation and step out if a resident was combative.
A CNA physically abused a resident with severe cognitive impairment after chasing the resident into a hallway over a banana. Surveillance video and staff interviews showed the CNA grabbing the resident by the neck, striking the resident on the head and upper back, and the resident falling to the floor and hitting their head on a wheelchair while another resident watched.
A resident with dementia, osteoporosis, and dependence for transfers was supposed to be moved with a Hoyer lift and 2-person assist, but an aide instead used a stand-pivot transfer to a shower chair. The resident screamed in pain during the transfer, and staff later found a fractured arm. Interviews and the incident review linked the injury to the care plan violation.
Resident-to-resident abuse occurred when one resident was observed on top of another resident with both hands around the other resident’s neck during a room altercation over a belt. The injured resident had bleeding from the nose, mouth, and toe and both residents were sent to hospitals. Records described the aggressor as alert and oriented with a history of behavioral altercations, while the other resident had multiple medical conditions and was not identified as physically aggressive toward peers.
Failure to Protect Resident from Physical Abuse: A resident with dementia and moderate cognitive impairment reported that a CNA hit them on the nose and grabbed their hand during care. Staff documented a skin tear to the arm and swelling to the nose bridge, and the resident was sent to the hospital for further evaluation. The facility’s investigation included conflicting staff accounts about whether the resident became combative and whether the CNA’s actions caused the injuries.
A resident with severe cognitive impairment and dementia was verbally and physically assaulted by another resident during meal service when the other resident yelled at them, grabbed both arms, and threw them back into a wheelchair. Staff separated the residents, and the abused resident was found with red marks and a scratch, then became visibly upset and cried, which the MD described as emotional trauma.
A resident with anxiety disorder, aphasia, and moderate cognitive impairment was aggressively redirected by a CNA, who forcefully assisted the resident into a chair and was verbally abusive. Staff reported the resident became agitated during the incident, and the facility’s investigation was inconclusive.
A resident with severe dementia and behavioral symptoms was physically abused by an aide during an encounter in another resident’s room. Surveillance video, a housekeeper’s statement, and the facility’s investigation showed the aide swore at the resident and pushed them backward, causing the resident to fall to the floor. The aide denied pushing the resident and said the resident threw themselves down, but the facility concluded abuse occurred.
Physical Abuse of a Cognitively Impaired Resident During Care: A resident with dementia and severely impaired cognition was involved in an altercation during incontinence care when an CNA struck the resident in the face after the resident spit and kicked at the CNA. An LPN observed the interaction, the resident had facial redness and pain, and the resident was sent out for ER evaluation.
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