Failure to Protect Resident from Physical Abuse During Incontinence Care: A CNA became combative during incontinence care for a resident with severe cognitive impairment, then straddled the resident in bed and applied pressure behind the ear while continuing care. The CNA later reported the incident to an LPN, who found no injuries, and the event was escalated through DON/MDS reporting.
A resident reported that a contracted travel CNA put hands inside his pants without consent while checking whether he was wet. Staff did not promptly escalate the allegation to the DON, and the administrator did not contact law enforcement because she believed reporting would wait until the facility determined whether abuse occurred. The resident had dementia, psychosis, insomnia, and anxiety, but his BIMS score indicated intact cognition and his care plan showed he was generally independent with toileting.
A CNA verbally abused a cognitively impaired resident with dementia and anxiety during morning walking rounds when the resident asked for assistance, responding with an expletive-laden statement and refusing help. Another CNA intervened by assisting the resident back to her room and directing the abusive CNA to leave. The involved CNA had prior training on abuse/neglect, residents' rights, and the facility's grievance policy, and maintained a current CNA certification with a clear background check, yet still engaged in this verbally abusive interaction, leading to a deficiency at F600.
Multiple residents with incontinence, impaired mobility, and high pressure-injury risk were not changed or repositioned as ordered or expected, resulting in prolonged periods in wet briefs, extended time in the same position, and failure to use pressure-relieving measures such as heel elevation. One resident with a history of coccyx pressure injury had a previously healed area reopened when a CNA cleaned the area roughly with a dry wipe and spray, causing a stage II ulcer, while another resident developed bright red, superficially open perineal and inner thigh areas after reporting that his brief had not been changed for a long time and that call lights often went unanswered for hours. Additional residents reported or were observed experiencing delayed toileting assistance, call lights out of reach, rough or non-communicative care, and refusal or failure by CNAs to provide requested hygiene or clothing changes, demonstrating neglect of basic care needs and, in one instance, abusive rough perineal care.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
A CNA failed to respond appropriately to call lights and did not provide required ADL, toileting, and incontinence care to two dependent residents during a night shift. One resident, with multiple comorbidities and moderate cognitive impairment, was left without toileting assistance after using the call light, and only received help when an LPN and RN intervened. Another resident, with obesity, TBI, contracture, and documented need for two-person assist and scheduled toileting, was not checked or toileted as care-planned. Both residents were later found with heavily saturated incontinence products and urine-soaked beds, and one developed moisture-associated skin damage to the buttocks.
A CNA verbally abused three residents during nighttime care interactions. One resident with moderate cognitive impairment and end-stage renal disease reported that the CNA responded to his call light with profanity and a hostile attitude when he requested help after a bowel movement. Another cognitively intact resident with multiple sclerosis stated that when she requested a female staff member to assist her into bed, the CNA became upset, left, and slammed her door, and she later heard the CNA arguing with a third resident who was crying. That third resident, who had quadriplegia and a colostomy, reported that the CNA did not know how to empty his colostomy bag, refused to get help from another staff member, shouted at him in a non-English language, and left the room, after which the resident was found crying and expressing emotional distress.
Failure to Protect Residents from Sexual Abuse During Incontinence Checks: A resident with intact cognition reported that a CNA pulled back her blankets and checked her brief in a way that startled her, and another cognitively intact resident reported that a female staff member put her hand down her pants and inside her underwear during a night shift to check if she was dry. The DON and SSD treated the first allegation as a lack of education rather than abuse, did not report it as required, and did not document or expand the investigation to other residents or staff. A COTA also reported that similar concerns had been raised by other residents.
A cognitively impaired resident with dementia and hearing loss, who frequently repeated requests and used the call light, was subjected to verbal abuse when a CNA allegedly told her to “shut the [expletive] up” in response to her calling out. A cognitively intact resident with an above-knee amputation, depression, and PTSD, whose room was across the hall, reported hearing the exchange and then seeing the CNA standing by the resident’s room, and multiple staff described this witness as reliable. Staff interviews further revealed that the CNA had appeared irritated and rude that shift, and an LPN reported a prior unreported incident in which the same CNA yelled at another resident. The facility’s abuse policy prohibits disparaging or derogatory language within a resident’s hearing, establishing that the resident was not protected from verbal abuse.
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