Failure to Protect Residents from Resident-to-Resident Abuse: A resident with vascular dementia, severe cognitive impairment, poor impulse control, and a history of aggression was involved in three physical altercations with three other residents within a 24-hour period. The resident knocked snacks from one resident’s hands and hit and kicked them, kicked another resident near the nurses’ station, and struck a third resident in the leg/ankle while agitated. One resident said the aggressor scared them and another said they did not feel safe around the aggressor; staff later stated the incidents constituted abuse.
Failure to Prevent Resident-to-Resident Physical Abuse: Two separate resident-to-resident altercations occurred in the dining room. In one incident, a resident slapped another resident during an argument, and in the other, a resident grabbed another resident’s arm, causing pain and superficial bruising. Staff interviews and incident investigations confirmed both events as physical abuse, and the DON stated the facility expected residents to be free from abuse.
Failure to protect a resident from sexual abuse when a CNA made repeated sexual comments over about 3 weeks. The resident, who had neurological and seizure disorders and was cognitively intact but dependent for most ADLs, reported the comments to an RN after initially thinking they were jokes. The allegation was substantiated, and the resident later stated they felt safe only after the CNA was no longer at the facility.
Failure to identify and manage a resident’s WV on admission. A resident returned from the hospital after hip surgery with a surgical wound and WV, but the admission record and MD orders did not include WV monitoring instructions. Nursing notes showed the WV alarmed and the canister became full, yet documentation of wound assessment, pain assessment, or provider notification was lacking. Interviews showed the DON and other leaders were not told about the WV before admission, staff had not been trained on the specific device, and the facility did not have the needed supplies when the WV malfunctioned.
Failure to protect residents from resident-to-resident physical abuse: two residents with dementia and significant cognitive impairment were involved in separate altercations with another resident who had a documented history of aggression. An LPN witnessed one resident being punched in the face and having a wheelchair kicked, while another incident involved the aggressive resident grabbing another resident's arm/hand after the resident came out of the room and approached the nursing station. Psychiatry notes recommending a behavior plan and clear communication were not reviewed or implemented.
A resident with muscle weakness and impaired cognition was struck in the face by another resident who had dementia with agitation and was identified as a high wander risk. Staff confirmed the resident wandered into other residents’ rooms, and the assigned 15-minute visual checks were difficult to complete because staff were also caring for other residents. The assaulted resident reported waking up to the intruder rummaging in the room and bathroom, then being hit in the face before calling law enforcement.
Failure to Protect Resident from Abuse: A resident with stroke, anxiety, depression, and cognitive impairment was roommates with another resident who had vascular dementia, severe cognitive impairment, and verbal behaviors. Staff heard a noise from the room and found the second resident bleeding from the upper lip with a water pitcher on the floor nearby; the resident had a 1.5 cm lip laceration. The resident later said they felt safe after the roommate was gone, and the roommate’s representative reported the resident admitted throwing the pitcher to hit the roommate.
Failure to prevent resident-to-resident physical abuse: A resident with moderately impaired cognition was hit on the side of the head by another resident with severely impaired cognition after the second resident tried to push the first resident’s wheelchair. Multiple residents reported the incident, and staff heard loud voices from the day room and later learned the second resident had struck the first resident.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
Failure to Protect Residents from Abuse and Neglect: A cognitively intact resident reported a CNA used a rude, dismissive tone, refused assistance, and made her try to care for herself, while a roommate corroborated the harsh treatment. Three other cognitively intact residents experienced delayed toileting or brief care, including prolonged waits after incontinence or call light use, and the facility later substantiated neglect tied to staffing-related delays. One incident was not documented in the incident log and was initially handled as a customer service issue rather than abuse.
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