Failure to Protect Resident from Physical Abuse: A resident reported that two CNAs were rough while moving them up in bed and bumped their head into the headboard, causing pain. Another resident heard the incident, and the DON and administrator later confirmed the abuse allegation and failure to report were substantiated after the facility investigation.
Failure to prevent resident-on-resident physical abuse: A resident with severe cognitive impairment and Alzheimer’s dementia grabbed another resident’s arm and clawed them during a dispute over food, causing a skin tear with moderate bleeding. The two residents then tried to hit each other before being separated by CNAs and an RN. The DON later stated the incident had not been known to them but should have been reported.
Failure to Protect Resident from Physical Abuse by Another Resident: A resident with severe cognitive impairment and dementia physically assaulted another severely cognitively impaired resident in a common area, grabbing the resident by the arms and throwing the resident to the floor. The injured resident was sent to the hospital and diagnosed with a closed displaced fx of the R femoral neck requiring surgical repair. The incident occurred while a CNA was assisting in another room and the day area was not covered as intended.
Failure to Protect Resident from Sexual Abuse: A cognitively intact resident touched a severely cognitively impaired resident's breast over clothing in a common area while a CNA witnessed the incident. The victim had severe cognitive impairment and diagnoses including frontotemporal neurocognitive disorder and traumatic brain injury, and the event was documented by the facility and police as sexual assault.
A resident was physically assaulted by another resident after a dispute over a TV remote escalated into threats and repeated punches to the face. A CNA was within view, gave a brief verbal command to stop, but did not effectively de-escalate the altercation and continued passing snacks while the resident was on the floor. The injured resident had schizophrenia, dementia, and agitation, and sustained facial skin tears and difficulty standing after the assault.
A resident was found touching another resident inappropriately through clothing, and the resident who was touched said no when asked if the contact was okay. The incident was not reported right away to OSDH or law enforcement, and the DON said the facility did not interview staff or residents to see whether other victims existed. The affected resident later became fearful, more isolative, and more agitated, and a psych eval noted increased anxiety and irritability.
A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
A resident sustained a leg fracture after being pushed to the ground by another resident in the smoking area following an altercation in which water was poured on one resident. Staff found the injured resident on the ground, yelling in pain and unable to get up, and hospital x‑rays confirmed a leg fracture. The resident who pushed had bipolar disorder, PTSD, depression, anxiety, and moderate cognitive impairment, yet their care plan did not identify behaviors or include a behavior care plan, despite facility policy requiring assessment and care plan interventions for residents at risk of abusing others. An LPN acknowledged that a behavior care plan should have been in place, while the administrator reported that the injured resident was considered the aggressor and that the other resident was generally not a problem unless unable to smoke.
A cognitively intact resident with paraplegia and an indwelling urinary catheter reported that when they approached an RN to discuss concerns about their catheter bag, the RN became angry, stated they did not care, and directed the resident to speak with someone else, causing the resident embarrassment and prompting them to return to their room. The facility’s abuse prevention policy required protection of residents from abuse by anyone, yet interviews and a grievance investigation confirmed that the RN had been verbally aggressive, including hollering and cursing, resulting in a substantiated finding of verbal abuse.
Multiple cognitively impaired residents experienced abuse or suspected abuse when one resident was found on the floor in a room with another resident pulling at their pants and partially exposing their underwear behind a makeshift barricade; in a separate case, a resident who was usually cheerful became tense and frightened, later found with fingertip‑sized bruises and crescent‑shaped skin tears after a CMA overheard two CNAs speaking about the resident in a derogatory manner; and in another incident, a CNA reported seeing a coworker strike a resident’s arm/hand several times after being hit by the resident, while the accused CNA described the contact as tapping in response to being grabbed, all occurring despite an abuse‑prevention policy.
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