Failure to Protect Resident from Sexual and Physical Abuse: A resident with dementia, PTSD, and a trauma history was involved in two separate incidents with other residents. In one event, a cognitively intact resident was observed on the resident’s bed with his penis exposed while the resident was holding his penis; the resident later had no recollection of the incident. In another altercation, two residents were seen fighting in the dining room, and the resident was left with scratches, bruising, and a fracture of the right 4th metatarsal after a wheelchair-related injury.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Failure to Protect Resident from Alleged Sexual Abuse: A resident with dementia-related diagnoses and memory impairment was involved in an alleged resident-to-resident sexual abuse incident when another resident was observed touching a female resident inappropriately. The BOM witnessed the resident leaning over the chair, with an arm around the female resident and a hand between her legs rubbing mid-thigh, after another resident alerted staff.
Failure to Protect Residents from Physical Abuse: Two residents were involved in separate resident-to-resident assaults after one resident entered another resident’s room and was punched in the chest, and another resident was punched during a hallway argument. One resident had severe cognitive impairment with a BIMS of 0 and required max assist with all ADLs, while the other had dementia, Alzheimer’s disease, CKD, and a BIMS of 3. Staff witnessed the incidents, and the facility’s abuse policy required zero tolerance for abuse and immediate reporting.
A resident was assaulted by another resident who entered the room and struck him in the chest, and the resident later reported being hit in the hand during the altercation. The incident resulted in a left thumb fracture confirmed by x-ray. The other resident had a history of aggressive behavior and prior monitoring, but was still able to access the room and cause harm.
No licensed nurse was available on a wing for about 12 hours after an LPN left without proper report or narcotic count and no relief nurse took over. Residents reported missed meds, untreated pain, insomnia, anxiety, and distress, and MARs showed bedtime meds were not signed off for multiple residents.
Failure to Protect Residents From Abuse and Neglect: The facility failed to protect two residents from abuse and neglect, including verbal abuse toward one resident with moderate cognitive impairment and neglect of another resident with severe cognitive impairment when care and medications were withheld. The record lacked documentation of proper investigations and state reporting for both incidents, and abuse education was not provided until well after the events. The facility’s own policy required immediate reporting, investigation, and notification, but those steps were not documented.
Failure to protect cognitively impaired residents from sexual abuse: A resident with dementia and a history of sexual inappropriateness was observed on more than one occasion groping two severely cognitively impaired residents, including a nonverbal resident who could not report the abuse. Staff interviews and clinical notes showed the behavior was known, but the resident was only redirected and there was no increase in supervision or restriction of access to other residents.
A cognitively intact resident with quadriplegia, PTSD, and total dependence on staff for care reported that staff ignored her call light, turned it off without helping, refused to enter her room, and left her in an unsafe position in bed. She stated that staff talked about her outside the room, police had to respond after she called for help, and she felt fear and anxiety because of the treatment. The DON acknowledged awareness that police were called and that an allegation of neglect had been made.
Staff failed to protect multiple cognitively impaired residents on a memory care unit from repeated abuse by an aggressive resident with dementia and behavioral disturbances. In separate incidents, one resident was pushed to the floor and sustained a head bump, another was found in bed with the aggressive resident while her brief was displaced and her buttocks exposed, a third was struck in the mouth and suffered a lip laceration after using a racial slur, and a fourth, who was on an anticoagulant for DVT, was struck in the eye during a struggle over a reacher and developed significant bruising and swelling before later deteriorating and being sent to the ED, with her family later reporting she died from a brain bleed. Documentation and interviews showed that the aggressive resident continued to wander the unit, enter female residents’ rooms, attempt to get into bed with them, and become physically aggressive when redirected, while staff and leadership were aware of both his escalating behaviors and the residents’ vulnerability.
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