A high fall-risk resident with severe cognitive impairment and a care plan requiring the bed to be kept in the lowest position was left with the bed elevated after a CNA, who observed the unsafe bed height during rounds, chose not to enter the room, lower the bed, or notify nursing staff. Minutes later, a visitor heard the resident yelling and found the resident on the floor near the bed, complaining of hip and leg pain. The resident was sent to the ER, where imaging showed a displaced intertrochanteric femur fracture requiring surgical repair. The facility’s investigation and video review confirmed that the CNA recognized the elevated bed and failed to intervene, in violation of fall prevention policies and the abuse/neglect policy.
A wheelchair‑dependent resident with ataxia, who required staff assistance for all ADLs, was transported to an appointment by a trained transport driver. The driver believed proper wheelchair restraints were not available in the van and, instead of reporting this, placed the resident’s wheelchair between seats and attempted to secure the resident with a regular van seat belt, despite knowing this was not the correct method. As the van exited the parking lot and hit a pothole, the rear door opened, the ramp deployed, and the resident rolled out of the van onto a gravel surface. The driver then assisted the resident back into a regular van seat and left the premises without notifying the ADM, DON, or other staff, contrary to facility policy requiring immediate reporting of all incidents and accidents during transport.
A resident with hemiplegia, multiple chronic conditions, and wheelchair dependence was transported by a CNA who failed to apply the van’s restraining lap belt, did not stop to reposition the resident after being told she was sliding, and left her unattended in the van while stopping at a personal residence. During this time, the resident slid from her wheelchair onto the floor of the van. The CNA returned, did not call the facility or seek assistance, and drove the resident back while she remained on the floor, without reporting when the fall occurred or how long the resident had been on the floor. The facility’s investigation, referencing existing abuse/neglect, fall management, and transportation safety policies and prior staff training, substantiated neglect and the situation was cited as Immediate Jeopardy.
A cognitively impaired resident with hemiplegia, Alzheimer’s disease, and dependence for transfers was subjected to physical abuse and unsafe transfer techniques by a CNA. Video showed the CNA entering without greeting, ignoring the resident’s request about food, repeatedly yelling at the resident to “Get up,” and forcefully pulling the resident up by the left upper arm without a gait belt, despite the resident grimacing and saying “Wait.” The CNA roughly manipulated the resident’s arm, rammed the wheelchair into the bed, lifted the resident by the underarms, and dropped the resident into an unlocked wheelchair, after which the resident cried out in pain and rubbed her left arm. Skin assessments later documented multiple reddish-purple areas on the back of the resident’s left upper arm resembling fingerprints. The Administrator and DON confirmed that the CNA’s actions constituted physical abuse and caused psychosocial harm, with the resident appearing frightened during the incident.
An LPN physically and verbally abused a resident who was moderately cognitively intact, repeatedly striking the resident’s face, head, shoulders, arms, and chin, kneeling on the resident’s neck, attempting to drag the resident by his shirt across the floor, and yelling profanities such as “b***h, don’t hit me” and “b***h, I’m tired of you” in the presence of staff and another cognitively intact resident. Two CNAs witnessed the abuse, briefly intervened to pull the LPN off when it appeared the resident could not breathe, but did not immediately report the incident to the Administrator or ensure the LPN was removed from resident contact; instead, they left the unit for several minutes to seek assistance, leaving the LPN alone with the abused resident and about 20 other residents, and later only intermittently monitored the situation while completing rounds. The Administrator and DON later acknowledged that the LPN should not have been left alone with residents after the abuse and that the abuse should not have occurred.
Two residents with cognitive and psychiatric conditions engaged in repeated physical altercations on consecutive days after an accusation of stolen soda. On the first day, a resident using a walker accused a wheelchair user of theft, after which the wheelchair user rammed the walker and struck the other resident's leg while a CNA was pushing her away. On the next day, the resident with the walker kicked the wheelchair user in the leg as she passed in the hallway, later admitting she did so in retaliation for the prior day's incident. An LPN documented both events, and the administrator was notified, but the facility did not effectively prevent or protect the residents from physical abuse by each other, contrary to its abuse prevention policy.
Two residents, both cognitively intact, experienced repeated inappropriate sexual advances and physical contact from another resident, including incidents in both public and private areas. The facility failed to implement ongoing monitoring or safety measures following these reports, resulting in a deficiency for not protecting residents from abuse.
A CNA verbally abused a resident with multiple medical conditions by using loud, profane, and derogatory language while assisting with mobility. The incident was captured on video by the resident's family and later confirmed through investigation. Although the resident did not report feeling abused, the CNA's conduct met the facility's definition of verbal abuse, and the facility failed to protect the resident's right to be free from such treatment.
Two residents with psychiatric and cognitive conditions engaged in a verbal altercation that escalated when one struck the other in the face with a chair, causing multiple facial fractures. Staff were present and intervened, but the incident resulted in significant injury before separation and assessment occurred. There were no prior documented physical altercations or behavioral changes between the residents.
A resident was physically struck in the face by another resident in the day room, with the incident witnessed by two CNAs and later confirmed by those involved. The facility's investigation substantiated that resident-to-resident abuse occurred, reflecting a failure to protect residents from physical mistreatment as required by policy.
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