A facility failed to protect residents from verbal, emotional, and physical abuse by staff and a contracted CNA. One resident was called a derogatory name, another had a CNA place a hand inside her brief while checking for incontinence, and two residents reported rough transfer care and rude, demeaning comments about room odors. The affected residents included individuals with impaired cognition as well as residents with intact cognition and diagnoses such as cerebral palsy, heart failure, and multiple sclerosis.
A CNA failed to return to change a resident’s saturated brief before a medical appointment, and the appointment was not completed. In a separate incident, a CNA/RMA saw that another resident needed two-person incontinence care, activated the call light, and left before the care was provided; the resident was later found with urine-saturated clothing. Both events were cited as neglect under F600.
Failure to Protect Resident from Physical Abuse: A CNA pinched and scratched a resident’s hand while assisting with eating, leaving bruising that was observed by an LPN. The resident had dementia with behavioral disturbances and moderately impaired cognition. The CNA’s statement claimed the resident grabbed her arm and asked to be pinched, scratched, and bruised, while the DON noted the CNA had a prior discipline history for being rough with residents.
Failure to protect a resident with severe cognitive impairment from physical abuse by a contracted travel CNA. Staff found bruising, a skin tear, and a lip cut after the resident reported that a staff member grabbed and twisted her arm. The CNA said she grabbed both forearms when the resident began to fall. The facility lacked complete investigation documentation, did not document required incident reporting in the risk management system, did not document family notification or IDT review, and did not show that the care plan addressed safety interventions related to the resident’s cognitive or behavioral status.
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.
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