A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
A resident with schizophrenia, severe cognitive impairment, traumatic brain injury, and documented aggressive behaviors physically assaulted another severely cognitively impaired resident who had no documented behavioral issues. The aggressive resident’s care plan identified risk for behavior problems and called for monitoring and behavioral interventions, yet he was able to engage in an altercation in which the other resident was found on the floor with the aggressor standing over him, flailing his arms. The injured resident sustained a scalp laceration and rib contusion. The DON reported there had been a previous incident between the same two residents and acknowledged not initially recognizing the severity of that earlier event, and the aggressive resident was not placed on 1:1 supervision but only on behavioral monitoring.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A resident with Parkinson's disease and limited mobility was not protected from another resident with dementia and a history of physical and verbal aggression. The roommate threw food and a tray at her, threatened to kill her, and staff interviews confirmed prior aggressive behavior and threats toward other residents. The resident stated she felt unsafe and feared being attacked, while staff acknowledged the roommate's behavior and the impact on the resident.
A resident with chronic respiratory failure, dementia, psychotic disturbance, mood disturbance, and anxiety reported that a CNA was nasty, aggressive, and pushed a fist against her private area during care, causing pain. The resident said she told the CNA to stop and did not want her providing care, but the concern was not promptly reported through the facility’s abuse process. A wound nurse received the resident’s written complaint but did not read it or report it, and leadership was unaware of the allegation until it was brought up later.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
The facility failed to protect residents from abuse and to correctly identify sexual abuse. One cognitively intact resident with dementia and occasional confusion was found in bed with another resident who had moderate cognitive impairment and impaired decision-making, where a CNA observed the cognitively impaired resident kissing the other on the lips and a roommate reported hearing kissing sounds and suggestive comments with laughter. Despite a policy defining sexual abuse as any non-consensual sexual contact and a legal guardian’s statement that the cognitively impaired resident could not consent, facility leadership concluded no sexual abuse occurred because the residents did not appear distressed and were viewed as capable of making their own decisions. In a separate incident, a cognitively intact resident with multiple serious medical conditions and bilateral leg amputation reported that an RCA refused to assist him back inside after a smoke break, used profanity, and threatened to pull him from his wheelchair and stomp on him; other residents corroborated the verbal altercation, and the RCA admitted refusing assistance and cursing at the resident.
Failure to Protect Residents from Abuse: A CNA was alleged to have kicked a resident with dementia while he was on the bathroom floor, and two other residents experienced resident-to-resident abuse from a cognitively impaired resident who stole food and exposed himself in a bathroom while making a sexual remark. The affected residents reported being scared or shocked, and the incidents were substantiated during the investigation.
A resident with paranoid schizophrenia and known behavioral disturbances verbally threatened another resident with violent, profane language in the activities room, leaving the threatened resident confused. The aggressor resident had a documented history of potential for verbal abuse related to mental illness and psychotropic medication use, as well as non‑compliance with medications, yet was still able to direct a specific threat toward another resident. The facility’s investigation substantiated this as an incident of verbal abuse, despite an existing policy prohibiting abuse, neglect, and exploitation.
Two residents with severe cognitive deficits were involved in an incident in which one resident, diagnosed with non-traumatic brain dysfunction and dementia, placed a pillow over the face of another resident with CAD, HTN, BPH, hyponatremia, and hyperlipidemia. The facility’s investigation and interviews with the DON and Administrator/Abuse Coordinator confirmed this as substantiated resident-to-resident abuse, in violation of the facility’s abuse, neglect, and exploitation policy that is intended to preserve each individual’s right to be free from mistreatment and abuse.
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