Failure to Implement Insulin Administration Policies Leads to Resident's Hospitalization
Summary
The facility failed to protect a resident from medical neglect by not implementing policies and procedures for insulin administration. On the morning of October 6, 2024, a resident with a history of type 1 diabetes and other significant health issues had a blood sugar level of 552. The resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new insulin orders to Staff B, another LPN, nor did they transcribe these orders into the medical record. Consequently, Staff B did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice on the same day, with the first call being dismissed by Staff B, who instructed EMS that the resident did not need help. However, during the second call, the resident was transferred to the hospital and admitted to the ICU with a diagnosis of Diabetic Ketoacidosis (DKA). The facility's failure to implement the policy and procedure for medical neglect and ensure residents requiring insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse in charge did not act within professional standards of practice for treating hyperglycemia in a type 1 diabetic. The Medical Director and other medical staff indicated that the professional standard of practice would have been to recheck the blood glucose after high readings and notify the provider of the resident's refusal of treatment. The facility did not follow its abuse and neglect policies, and there was a failure to conduct a thorough investigation or implement corrective actions promptly.
Removal Plan
- The Executive Director completed a 30-day look back at all reportables to ensure proper investigation was conducted.
- The Director of Nursing completed all hospital transfers, conducted a facility wide audit of change in conditions pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided to the Executive Director by the Regional President on Abuse/Neglect policy and procedure to include investigations.
- The Regional Nurse Consultant provided abuse/neglect education, as well as investigation to the nurse management staff.
- Education included: abuse/neglect policy and procedure related to neglect for failure to reassess, notify the physician, not documenting physician's orders, not documenting communication to the physician, not documenting the transfer of the resident to the hospital, not following physician orders, and lack of shift-to-shift report.
- All incidents to be called to the Regional President, Regional Director of Clinical Services, and Risk Manager with a timeline of events on any incident to determine if reportable.
- Investigations to be started immediately on any complaints or incidents.
- The grievance log was reviewed for concerns related to change of condition, insulin, abuse or neglect.
- The Director of Nursing conducted a facility wide audit of all hospital transfers and change of condition pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided for all staff by the Director of Nursing/designee on the abuse neglect policy.
- Facility personnel received education related to the abuse/neglect policy to include preventing abuse, identification, protection, investigating and reporting inappropriate resident behaviors to the nurse.
- Key staff were educated on reporting process of a potential deficient practice or suspected abuse/neglect to the Quality Assurance performance Improvement (QA/PI) by notifying the Executive Director and/or the Director of Nursing.
- An Ad Hoc that included the Executive Director, Medical Director, Director of Nursing the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation.
- Education has been completed on licensed nurses on medical neglect, accuchecks, insulin, Type 1 and 2 diabetes, and Change of Condition policy.
- Certified Nursing Assistants and ancillary staff were also educated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Abuse During Incontinent Care: A CNA was observed on video using forceful and aggressive handling while providing incontinent care to a resident with severe cognitive impairment and total ADL dependence. The resident yelled, moaned, and repeatedly asked what he had done while the CNA grabbed his wrists, turned him forcefully, held him down, and moved his limbs without speaking. Later, the resident told staff and family that a tall man had entered his room, held him down, and hit him, and the CNA admitted he had gotten rough and restrained the resident during care.
A resident with severe cognitive impairment and a history of combative behavior during care was being assisted by two CNAs with incontinence care when the resident became resistive and kicked one CNA in the leg. Instead of following the care plan directive to stop care and return later when the resident was physically abusive, the CNA immediately retaliated by open-handedly slapping the resident hard in the face, causing visible redness and leaving the resident appearing stunned and fearful. The second CNA, who witnessed the slap, briefly left the room to report the incident to the nurse, leaving the resident alone with the CNA who had just abused him, thereby failing to ensure the resident’s immediate protection from further abuse.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
A resident with a history of TBI, anxiety, and mild neurocognitive disorder became agitated after staff moved a wheelchair he had positioned to avoid blocking his window view, leading to escalating verbal aggression toward staff. Witnesses reported that when the resident approached the nurses’ station with clenched fists and swung at an RN, the RN grabbed the resident’s arm and/or shoulder and took him to the floor, then restrained him there until supervisors arrived. Immediately afterward, the resident complained of severe left hip pain, with clinical signs of injury, and hospital evaluation confirmed a left comminuted displaced intertrochanteric fracture requiring surgical repair. Multiple staff later stated that they are not allowed to restrain residents and would instead use de-escalation, walk away, or call for assistance when residents are aggressive, while the DON acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm.
Abuse During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA used forceful and aggressive handling during incontinent care. The resident was a male with severe cognitive impairment, including a BIMS score of 0, and diagnoses that included heart failure, hypertension, end stage renal disease, Alzheimer's disease, stroke, and non-Alzheimer's dementia. He was dependent for ADLs and required assistance from one staff member for care. During the early morning care episode, video footage showed the CNA entering the resident's room, turning on the light, removing the covers, and then grabbing the resident's wrists and forcefully turning him onto his side while removing the brief. The CNA placed his weight on the resident's shoulder, then later pushed the resident to the opposite side, grabbed the resident's wrist again, and forcefully yanked him over while the resident yelled and moaned in distress. The footage also showed the CNA crossing the resident's wrists over his chest, holding him down while adjusting the brief, and grabbing the resident's ankles and moving them toward the center of the bed. Throughout the incident, the CNA did not speak to the resident, and the resident repeatedly asked what he had done. Later that morning, the resident told staff and family that a tall man had entered his room during the night, held him down, and hit him on the face. He said he felt fearful and did not want that man in his room again. Staff who interviewed the resident reported that his account remained consistent, and multiple staff stated the resident had not been combative during care and had not previously made similar allegations. The CNA acknowledged that he had gotten rough with the resident, restrained him while putting on the brief, and admitted he probably should have stopped when the resident was yelling and asking him to stop.
Resident Physically Abused by CNA and Left Unprotected After Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to ensure immediate protection from further abuse once an incident occurred. An elderly male resident with heart failure, unspecified dementia with agitation and other behaviors, and Alzheimer’s disease was admitted to the facility and had a BIMS score of 0, indicating severe cognitive impairment. His care plan documented impaired cognitive function and a history of becoming combative with staff at times, with interventions directing staff not to attempt care when he was physically abusive and to allow time and revisit the task later. Despite these documented needs and interventions, the resident was subjected to physical abuse by a CNA during routine care. On the day of the incident, two CNAs entered the resident’s room to perform routine rounds and provide incontinence care while he was in bed. According to statements and interviews, the resident was awakened, his clothing and brief were removed, and as care proceeded he became resistive and combative. The resident swung and kicked, striking one CNA on the leg. In response, that CNA immediately and open-handedly slapped the resident in the face/forehead. The slap was described by the witnessing CNA as very hard, leaving the left side of the resident’s face a little red and causing the resident to appear stunned, frozen, and nervous, as if afraid to move. The CNA who slapped the resident admitted in her written and verbal statements that she hit him back after he kicked her leg, characterizing it as a reaction. The facility also failed to ensure the resident was protected from further abuse at the time of the incident. After witnessing the slap, the second CNA briefly left the room to notify the nurse, leaving the resident alone with the CNA who had just physically abused him. During this interval, the abusive CNA remained in the room with the resident, and there is no indication that the resident was immediately removed from the abuser or that the abuser was immediately removed from the resident’s presence before the witness left to report the event. This sequence of actions and inactions—failure to follow the resident’s care plan for managing combative behavior, the CNA’s retaliatory slap, and the witness CNA’s decision to leave the resident alone with the abuser—constituted the failure to ensure the resident was free from abuse and protected from further abuse.
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Resident From Physical Abuse Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse when a registered nurse (RN) took the resident to the floor during an altercation, resulting in a left comminuted displaced intertrochanteric hip fracture that required surgery. Facility policy on "Abuse: Protection From" stated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property, and that residents must not be subjected to abuse by anyone, including staff. The resident involved had a history of traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance, but was assessed as cognitively intact with a BIMS score of 13. On the evening of the incident, the resident became agitated after staff moved a wheelchair that he had positioned to avoid blocking his window view, and he began yelling and cursing at a nurse aide (NA) about the wheelchair placement. According to multiple staff statements and nursing documentation, the resident paced in his room, continued yelling, and then left the room to go to the bathroom. After several minutes, he approached the nursing station, yelling and threatening the RN, with witnesses reporting that he had his fists clenched and was swinging at the nurse. The RN reported that when the resident swung at him, he grabbed the resident’s arm and/or shoulder and took him down or assisted him to the floor, then restrained him there until supervisors arrived. Witnesses, including NAs and another RN, consistently described the nurse catching the resident’s swing by the forearm or grabbing his shoulder/arm and putting or sitting him down on the floor, after which the resident was observed lying on his right side in front of the elevator, screaming in pain and holding his left hip. Following the takedown, staff observed that the resident complained of 10/10 left hip pain, with the left leg shortened and externally rotated. The resident told staff and later hospital providers that the nurse had “tackled” him to the floor. Hospital records documented that the resident reported being tackled after an altercation about moving a wheelchair to see the sunset, and confirmed a left comminuted displaced intertrochanteric fracture requiring orthopedic surgical intervention. In subsequent staff interviews, multiple nurses and NAs stated that facility practice when a resident exhibits aggressive behavior is to walk away, call for help or a supervisor, attempt de-escalation, remove triggers, and that they are not allowed to restrain residents or hold them to the ground. The Director of Nursing acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm in the form of the hip fracture. The deficiency was cited under multiple Pennsylvania regulatory provisions, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 201.18(b)(1)(3) Management, 201.29(a)(c)(d)(j) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3) Nursing services. These citations reflect that the resident’s right to be free from abuse and the facility’s obligations regarding resident care policies and nursing services were not upheld in this incident, as evidenced by the RN’s physical handling of the resident that led to a serious injury.
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