A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Abuse of Two Cognitively Intact Residents by Nurse Aide: A nurse aide verbally and physically abused two cognitively intact residents during the overnight shift. One resident, who had quadriplegia, chronic pain, and muscle weakness, was cursed at, threatened with sexual profanity, and had the aide get in his face while turning off his call bell. Another resident, who had depression and cancer, was denied help with a urinal, cursed at, spit on, and had the urinal thrown across the room. Witness statements and resident interviews supported the allegations.
Failure to protect a resident from verbal abuse: A resident with osteoarthritis, polyneuropathy, depression, anxiety, and muscle weakness required 2-person assist for transfers when an NA allegedly spoke to her in an aggressive and inappropriate manner, told her to shut up, called her a b*tch, placed a hand over her mouth, and told her to shut the f*ck up while assisting her back to bed. Another NA reported the incident immediately, and the RN assessment found no injury.
A resident with difficulty walking and bilateral knee contractures required max assist x 2 for bed mobility, but a nurse aide provided care without a second staff member. The resident rolled out of bed during care, complained of pain, and was later diagnosed with a closed distal femur fracture that required surgery. The NHA confirmed the aide did not follow the resident’s care plan.
A resident with severe neurologic impairment, aphasia, and total dependence for care was found with dried blood, abrasions, scratches, and ecchymosis after reporting that an RN hurt him during incontinence care. Staff documented that the resident consistently stated the RN pinched, hit, and held him down while providing care, and the DON later substantiated physical abuse.
A resident with dementia, muscle weakness, and dependence for transfers was moved from a wheelchair to bed by a nurse aide using a bear hug instead of the required 2-person assist with a gait belt. The resident later had pain, swelling, and abnormal positioning of the leg, and hospital imaging showed fractures of the shin and ankle. The DON confirmed the aide did not follow the care plan and was negligent in the transfer.
A resident with morbid obesity, DM, muscle weakness, an artificial knee joint, and cognitive decline was supposed to be transferred with a sit-to-stand lift, but CNAs attempted a stand-pivot transfer to a shower chair instead. The chair slid, the resident was lowered to the floor, and the resident later reported pain; an x-ray showed an acute distal femur fracture, and the resident was sent out for surgical intervention. Staff also failed to timely report the fall to the nursing supervisor.
A resident with Alzheimer’s disease, dementia with psychotic disturbance, anxiety, insomnia, memory impairment, and urinary incontinence was slapped in the face by a CNA during an attempt to provide incontinence care after the resident spit in the CNA’s face. Another CNA witnessed the event, and the incident was substantiated by the CNA’s admission.
A resident with dementia and severe cognitive impairment was physically handled forcefully by an NA during incontinence care. The resident's care plan directed two-staff toileting assistance, in-bed incontinence care, and stopping care if behavioral interventions were ineffective, but one NA grabbed the resident's arms, held the resident's mouth, and continued care while the resident resisted and was jerked during repositioning. A second NA witnessed the forceful actions and reported them to the nurse and supervisor.
A resident with dementia and a care plan requiring a mechanical lift with two staff was injured when an aide used the lift alone during care. The resident developed a large hematoma to the arm and a fractured finger, and the facility’s investigation determined the aide likely caught the resident’s arm and hand between the lift bar and chair, substantiating staff-to-resident neglect.
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