A facility failed to keep supervision in place during a smoke break, and two residents became involved in a verbal and physical altercation. One resident with dementia and aggression-related care plans and another resident with bipolar disorder and verbal aggression began arguing, exchanged insults, and one resident grabbed the other and pushed her to the ground, causing bruising and back pain. Staff left the smoking area to get help or retrieve smoking materials, and observations confirmed the supervisor was out of sight of the residents during smoking.
A nurse attempted to give crushed Ativan mixed with applesauce to an unresponsive resident with terminal decline, severe cognitive impairment, and end-of-life morphine/lorazepam orders. Despite the hospice nurse warning that the resident was no longer able to swallow and could aspirate, the nurse placed the applesauce in the resident’s mouth, prompting the resident’s daughter to order her out of the room. The family, hospice nurse, and son witnessed the event and described it as abusive, while facility leadership later said they did not consider it abuse or report/investigate it.
Neglect of wound care, tube feeding, and basic ADL support. A resident with severe cognitive impairment, autism, malnutrition, immobility, incontinence, and a very high pressure injury risk had a new Stage 3 groin pressure ulcer, but ordered wound care was delayed and then repeatedly missed or not documented. Staff also failed to consistently provide or document PEG feeding, meal assistance, bathing, and oral care; trays were often left untouched or out of reach, the facility ran out of formula, and the resident was not on the feeding-assistance list despite being totally dependent.
A CNA was identified by police as the alleged perpetrator of credit card fraud involving multiple residents’ accounts, including a resident who reported prior fraudulent activity and another resident whose card information was found in the CNA’s Amazon account. Additional residents were later identified as potential victims after suspicious bank and Cash App charges were reported, and the CNA admitted to using a resident’s credit card number without authorization.
Failure to Individualize Care Plan for Resident with Sexual Behaviors: A resident with dementia, severe cognitive impairment, and a history of sexually inappropriate behaviors was not given individualized care-planned interventions to address those behaviors. Staff notes referenced inappropriate comments and touching attempts, but the care plan remained generalized and did not document the sexual behaviors. Two cognitively impaired residents were later found naked together in one resident’s bed, and interviews showed inconsistent accounts about consent and understanding.
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.
A resident with Lewy Bodies dementia, Parkinson’s disease, and cognitive impairment was physically abused during routine care when a CNA slapped his arm after he squeezed her finger. The incident was witnessed by an RN and another CNA, who both reported that the CNA yelled and struck the resident before the RN stopped her from continuing care. The allegation was later substantiated by the facility.
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.
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