Failure to Prevent Staff-to-Resident Verbal Abuse: A resident with intact cognition and multiple medical diagnoses was involved in an escalating interaction with the Administrator over the smoking policy while recording on his phone. The Administrator made an inappropriate hand gesture toward the resident, and the resident reported the Administrator also placed hands on his shoulders and took the phone. Police reviewed the video and saw the gesture but no assault, and the SSD stated he believed the incident was verbal abuse.
Failure to Protect Resident from Abuse: An LPN physically restrained a cognitively impaired resident by grabbing the resident’s wrists and pinning them to the wheelchair armrests during a redirection attempt, while making threatening statements about hitting the resident back and calling the police. The incident was witnessed and later described by multiple staff members, and staff who knew about it did not report it at the time.
Physical Abuse During Personal Care: A resident with severely impaired cognition and dependence on staff for ADLs reported that a CNA slapped her hands during night-shift personal care and told her, "when we say no we mean no." The resident identified the CNA from photos, and the DON stated the resident's account remained consistent during the investigation. The CNA did not confirm or deny the allegation and had a prior written warning for resident care concerns.
The facility failed to develop and implement individualized interventions to prevent repeated resident-to-resident physical abuse between two cognitively intact residents. One resident with schizoaffective disorder, MDD, and HTN and another resident with COPD, bipolar disorder, and alcohol dependence were involved in two separate altercations: one in a smoke line after threats were made, and another in a hallway where one resident was struck in the face and his glasses were broken. Records showed no additional individualized interventions beyond short-term 15-minute checks after the first incident.
A resident with multiple chronic conditions and documented behavioral issues became involved in an altercation with an agency CNA near the nurse’s station after a dispute over hallway noise. The resident and CNA gave conflicting accounts about who initiated contact, but the resident had visible facial scratches and a skin tear, and the CNA stated she recorded the incident on her phone. A nurse witnessed part of the event and reported the resident was trying to kick at the CNA while the CNA continued responding verbally to the resident’s racial slurs.
A severely cognitively impaired, nonverbal resident who was dependent for all ADLs was left without food, fluids, or incontinence care for about 12 hours after staff mistook one family visit for another and believed the resident had left the unit. The resident was later found sitting in a Broda chair in a hallway nook, extremely soiled, after staff learned from family that she had never left the facility.
A resident with severe cognitive impairment, dementia, and agitation was verbally abused during hands-on care when a CNA used inappropriate and unprofessional language. Staff later reported that an audio recording existed and had been shared, and the facility’s investigation substantiated the verbal abuse after reviewing the recording and staff statements.
Verbal Abuse Toward a Resident During Smoking Incident: A cognitively intact resident with multiple medical diagnoses was identified as a supervised smoker after being observed smoking outside the designated area. The former DON yelled at the resident in front of others, followed her into the hallway, and threatened to take her cigarettes and lighter. Staff described the DON’s tone as aggressive, degrading, and belittling, and the resident was crying and embarrassed. The facility substantiated the allegation of staff-to-resident verbal/emotional abuse.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A cognitively impaired resident with dementia and behavioral symptoms became involved in a physical altercation with another resident and was then taken to the nurses’ station, where three CNAs forcefully seated him in a chair, held his arms down, and one CNA straddled his leg while others pulled up on his sweatpants. Video showed the resident being repeatedly pushed back into the chair and physically restrained by multiple CNAs, while cognitively intact residents and a CNA witness reported that staff were laughing, teasing him, and making demeaning comments as he tried to get up and walk away. The resident was later found to have a bruise and skin tear of unknown origin on his arm, exhibited increased agitation, and was placed on Depakote for behavioral management for two days before it was discontinued. The facility’s investigation, including review of video and witness statements, substantiated that the CNAs’ actions constituted physical abuse and a violation of the resident’s rights.
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