A resident with severe cognitive impairment, dementia, hallucinations, delusions, and a documented pattern of physical and verbal aggression was allowed to ambulate freely and repeatedly exhibit disruptive and threatening behaviors toward others without behavior‑specific care plan interventions. This resident ultimately slapped another cognitively intact resident on the upper arm in a hallway confrontation, causing pain and a red mark, after staff were unable to separate them in time. Following this event, the assaulted resident, who had a history of anxiety and depression, reported increased anxiety, fear of being hit again, social withdrawal to her room, use of headphones during meals to block out the aggressive resident’s outbursts, and reduced meal intake, while staff observed her crying and avoiding interaction. Two other cognitively intact residents also reported being scared of the aggressive resident, limiting their time out of their rooms and declining activities due to her yelling, screaming, and perceived risk of being hit. Staff interviews and documentation confirmed that the aggressive resident’s behaviors had worsened over months, that other residents were fearful, and that the care plan did not include interventions for the known aggressive behaviors, despite an abuse policy prohibiting physical abuse such as hitting and slapping by other residents.
A cognitively impaired, non-verbal resident with Alzheimer’s disease and total dependence for ADLs was being assisted by two CNAs with evening toileting and dressing using a mechanical lift when the resident became agitated and combative. One CNA reported that the other CNA appeared irritated, raised her voice, continued care despite the resident’s resistance, and, while the reporting CNA was holding both of the resident’s hands to calm him, struck the resident’s face with an open hand, causing a cut to the lip and a scratch to the cheek. A nurse later documented fresh facial injuries consistent with this account, and subsequent notes recorded healing scratches and bruising, demonstrating that the resident was not kept free from physical abuse by staff as required by the facility’s abuse policy.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with severe dementia, behavioral symptoms, and total dependence on staff for care was being assisted in bed by two CNAs when the resident jabbed one CNA in the eye. According to an eyewitness CNA and multiple staff interviews, the CNA who was struck became angry, grabbed the resident by the shoulders, shook him, and loudly cursed at him, telling him to "shut the f**k up" and making additional threatening statements, while the roommate overheard profanity directed at the resident. The charge RN was informed that the CNA had yelled at and grabbed the resident, and an assessment showed no physical injury, but the facility’s investigation concluded that the CNA had verbally abused the resident and that physical abuse in the form of aggressively grabbing the resident’s shoulders had been reported, in violation of the facility’s abuse-prevention policy.
Failure to prevent resident-to-resident abuse: A resident with severe cognitive impairment and a history of aggression toward others struck another resident while seated near an LPN/CNA. The staff member did not intervene until after the hit, despite knowing the resident had prior behavioral issues, including yelling at others, taking belongings, and placing hands on another resident.
Two residents were not protected from abuse when one cognitively impaired, non-ambulatory resident who preferred to stay in common areas was reportedly placed in his room with the door closed by a CNA to avoid his vocalizations, keeping him there for an extended period despite his gestures indicating he wanted to leave, as corroborated by his roommate and an RN. In a separate incident, a resident with dementia and mood disorders was observed by an RN being kissed twice on the mouth and held around the waist by a female visitor later identified as a facility cook, and later seen walking hand-in-hand with her, while the same staff member had also sought to take another resident out overnight and obtain that resident’s medications without guardian consent. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation but did not address how residents would be protected during investigations, and the described events demonstrate failures to prevent unreasonable confinement and potential sexual exploitation.
A resident with multiple medical conditions and moderate cognitive impairment, seated near the nurses’ station while on the phone, swung his arm back and struck another resident with severe dementia twice in the upper back as she self-propelled her wheelchair past him, following her usual routine. Staff reported that this resident could become irritable when redirected, and he then stood up and hit and pinched a CNA who intervened. The aggressor’s care plan identified mood and behavior issues and directed staff to anticipate needs, provide positive interaction, and intervene to protect others’ safety, while the other resident’s care plan addressed impaired cognition and the need for supervision and consistent routine. The facility’s abuse policy states residents must be protected from abuse by anyone, including other residents.
Multiple residents reported that a CNA was verbally abusive, rough, and impatient during care, including yelling in the hallway, entering rooms without knocking, speaking in a bossy manner, throwing incontinence pads toward a resident, and refusing to assist with turning, which led one dependent resident to remain in a urine-soaked brief for several hours out of fear. Another resident described being treated like nothing and being scared of the CNA. A cognitively impaired resident with Parkinson’s disease was later found with multiple bruises on her thighs and leg, complained of pain all over, and told family and hospital staff that facility staff were mean, had told her her husband no longer wanted her, and that she had been put on the floor by many people in a surprise attack. EMS and hospital records documented multiple contusions and confirmed adult physical abuse, and the facility’s QA investigation noted that several residents on the same hall described the CNA as not kind, rough during care, and impatient, with findings consistent with abuse.
A resident with a history of mental illness repeatedly engaged in physical and verbal aggression toward other residents and staff, resulting in multiple altercations. Despite existing care plans and interventions, the facility did not consistently update documentation or adjust interventions after incidents, and staff interviews confirmed ongoing aggressive behaviors. The facility's failure to prevent and properly document these incidents led to emotional and physical distress among affected residents.
A resident dependent on staff for tracheostomy care experienced repeated delays and refusals of suctioning by an LPN, despite physician orders for as-needed suctioning. The resident reported severe anxiety and fear due to these delays, and multiple CNAs confirmed the LPN's pattern of not responding promptly to requests. The DON was informed of concerns but did not initially identify any issues with the LPN's performance, and documentation of suctioning was lacking.
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