Failure to protect a resident from physical abuse occurred when one resident struck another resident several times in the face, head, and neck during a planned activity in the dining room. The injured resident had Parkinson’s disease with dyskinesia and moderate cognitive impairment, while the other resident was cognitively intact; the residents later gave conflicting accounts, including allegations of racial slurs and profanity.
A resident with stroke-related deficits, ataxia, and delusional d/o was involved in abusive incidents with two other residents. One resident reported verbal threats, sexual harassment, yelling, and derogatory name-calling, along with a prior episode where the resident shoved a table into the resident’s abdomen and grabbed a TV remote. Another resident with HF, kidney disease, and dementia was observed by an RN being kicked in the leg during a hallway altercation. The DON identified the first incident as verbal abuse and the second as physical abuse.
Failure to Protect Residents from Abuse: Two residents with severe cognitive impairment and dementia-related behaviors were assaulted by another resident in the secured memory care unit. One resident was punched in the shoulder and neck, and another was punched in the mouth causing a bleeding lip. Staff reported aides were busy preparing other residents for lunch, and an observed recreation therapist near the unit entrance had no RN/CNA support and no radio or phone to call for help.
Failure to protect residents from abuse occurred when one resident was involved in repeated altercations with other residents in the dining room and doorway areas. The resident threw objects, twisted another resident’s finger, and threw cups during arguments, causing pain and distress to affected residents. Staff and the DON confirmed the resident was easily irritated and required 1:1 supervision around other residents.
A resident-to-resident altercation involved one resident grabbing, hitting, threatening, and verbally abusing another resident, while also poking a second resident. The abused resident reported fear and nervousness, and a witness described the aggressor following the resident, touching the resident's back, and attempting to kick them. The aggressor had cognitive impairment and a history of inappropriate interactions, and the second resident had dementia and severe cognitive impairment.
Failure to Protect Resident from Alleged Physical Abuse: A resident with moderate cognitive impairment and a prior sacral fracture alleged that an unidentified male entered the room, twisted the resident’s hand, and caused bruising, swelling, and pain to the left hand and pinky. The allegation was reported to nursing, the resident was assessed and treated for pain, and an x-ray showed OA with no fracture, but leadership could not explain how the abuse allegation was ruled out.
Neglect of 3 residents by nursing staff. A cognitively intact resident with a care plan for 2-person sit-to-stand transfers said a CNA used the lift alone, causing the resident to slide to the floor and sustain bruising and pain. A moderately cognitively impaired resident with fall and bleeding risk said aides helped them back to bed after a fall without RN assessment, and an RN delayed the incident report. Another cognitively intact resident said an RN walking while talking on a cell phone struck the resident's foot and did not stop to assess the injury.
Failure to protect a resident from sexual abuse occurred when one resident touched another resident's breast in the dining room. The abused resident had dementia and severely impaired cognition, while the other resident had a history of inappropriate sexual behaviors and diagnoses including a CVA, MDD, and anxiety disorder. A RN observed the contact, separated the residents, and the touched resident stated they did not want it to happen. Staff interviews showed disagreement about whether the event was abuse, despite the RN identifying it as sexual abuse.
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.
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