An agency NA forcefully pushed a wheelchair-bound resident through a doorway while the resident was caught in the frame, causing the resident’s foot to strike both shins and resulting in bruising, swelling, pain, and an acute right tibia fracture. The resident had dementia, muscle weakness, and required assistance with mobility and transfers. CCTV and the facility’s investigation showed the NA did not follow safety measures during the transfer.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
Failure to supervise an aggressive resident led to resident-to-resident abuse. A resident with a history of wandering, exit-seeking, verbal aggression, and prior physical aggression toward staff and peers was not on 1:1 or 15-minute checks when he became agitated, entered another resident’s room, and pushed her into a wall. The other resident fell, sustained a hip fracture, and required hospital transfer and surgical repair.
An agency CNA posted a social media image of a cognitively impaired resident showing the resident from behind without a shirt, with pants partially down and profanity on the image. The resident was nonverbal, had severe cognitive impairment, and exhibited pacing and clothing-removal behaviors. The facility substantiated abuse related to the post, which was described as causing harm and humiliation.
Failure to Protect Resident from Sexual Abuse: A cognitively intact resident with hemiplegia, aphasia, MDD, and anxiety reported that a nurse aide kissed the resident without consent during care and then touched the resident’s breasts and genital area after offering a massage. The resident became emotionally distressed, tearful, and overwhelmed, with later reports of severe nightmares and resurfaced prior trauma; psychiatry diagnosed PTSD.
Unauthorized Recording of Resident During Toileting Care: An NA used a personal cell phone to record a resident during toileting and while the resident was on the toilet without consent, then showed the video to other staff. The resident had dementia with psychotic disturbance, moderate cognitive impairment, and required moderate assistance with toilet transfers. The NA said she recorded the resident because she was tired of the resident’s behavior and wanted proof to protect herself, despite knowing policy prohibited recording residents.
Neglect during assisted ambulation resulted in a resident fall and fracture. A CNA assisted a non-ambulatory, cognitively impaired resident from the bathroom without a walker or gait belt, despite the resident’s care needs and fall risk status. The resident’s knee buckled, the resident fell to the floor, and later required hospital transfer with a left periprosthetic femur fracture. The facility substantiated neglect in its investigation.
A resident who was totally dependent for all care and had quadriplegia and cervical spinal fusion was involved in a verbal altercation with an aide during personal care. Witness statements and the resident’s report indicated the aide used profane, derogatory language and made threats, and the NHA and DON confirmed the behavior was verbal abuse.
Failure to Protect Resident from Staff Physical Abuse Resulting in Rib Fracture: A resident with dementia and resistance to care was found with an aide on top of him while the resident was yelling and out of breath during incontinence care. Subsequent skin checks documented bruising, abrasions, swelling, and lip injury across multiple body areas, and x-ray results confirmed an acute displaced fracture of the right 7th rib. The facility substantiated staff-to-resident physical abuse, and records showed the aide and other agency staff lacked evidence of required abuse-prevention training.
A resident with dementia, depression, and weakness was injured when a CNA transported the resident in a Broda chair without the required footrests/leg rests. The resident's foot dropped and became caught under the chair, causing pain, swelling, bruising, and an acute non-displaced fracture of the ankle. Staff statements and the facility investigation confirmed the footrests were missing during the transport and that the CNA did not follow the resident's care plan and facility policy.
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