Failure to Protect Resident from Verbal Abuse: An LPN yelled at a resident after the resident spit on a CNA, made scolding and threatening comments about jail, and was reported by multiple residents and staff as rude, mean, and verbally aggressive. Staff also reported the LPN said they were no longer in camera view and one witness stated the LPN slapped the resident's hand while yelling.
Failure to Protect Residents from Sexual Abuse: A memory care resident with severe cognitive impairment, wandering, and behavioral issues was observed touching and kissing another resident inappropriately, including contact to the groin, chest, and face. A separate resident with dementia and moderate cognitive impairment reported the same resident entered their room at night and touched their breast/shoulder area. The DON stated resident behaviors were tracked daily, but there was no documentation of the behavioral findings or IDT tracking.
Physical intervention during meal service: A CNA yelled at a resident, then grasped the resident’s hand, pulled it downward, and removed food the resident had picked up from another resident’s plate. The resident had memory deficits and could not easily make self-understood, and the care plan listed a mechanical soft diet with no dairy restrictions. The CNA said the action was taken because the meal might upset the resident’s stomach and cause diarrhea.
Failure to protect a resident from sexual abuse by another resident. A resident with dementia and sexual dysfunction had documented wandering, yelling, and sexual behaviors and was on close observation, yet still entered another resident’s room and rubbed the resident’s crotch over clothing while the resident was asleep. The affected resident later reported being fondled in the crotch area and said the incident was traumatic. Staff also documented ongoing sexually inappropriate behavior and comments from the resident, including during transport, and the DON stated they did not question the use of Provera.
A resident with intact cognition was verbally abused by the dietary manager after requesting an alternate meal when dissatisfied with lunch. The manager yelled at the resident, another staff member intervened, and the resident later cried in their room. The incident was investigated, and the abuse was substantiated.
Failure to Protect Residents from Abuse by Another Resident: A resident with documented poor impulse control and a history of slapping others physically and verbally abused multiple residents, including pulling one resident from a chair, slapping another resident in the face, snatching a bingo card and using a vulgar slur toward a resident during an activity, and hitting another resident on the shoulder. Several of the affected residents had severe cognitive impairment, and the DON stated the facility did not conduct thorough investigations for the incidents.
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.
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