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.
The facility failed to protect residents from abuse when two residents with cognitive and behavioral issues inappropriately touched other residents in common areas without effective supervision. In one case, a cognitively impaired resident touched another resident’s leg and later was reported to have touched a female resident’s leg and between her thighs. In another case, a cognitively intact resident with prior documented inappropriate touching was confirmed by video to have touched a resident’s breast in a hallway. Affected residents reported the incidents to staff, but documentation was incomplete, follow-up with the victims was limited, and communication about the incidents and protective measures was insufficient, resulting in a failure to uphold residents’ rights to be free from abuse and to feel safe.
A resident with dementia and recent right femur fracture, requiring wheelchair use and one-person assist for stand-pivot transfers, was subjected to verbally abusive, demeaning, and intimidating treatment by two CNAs during care, while repeatedly requesting help and complaining of pain. Two additional CNAs were present for part of the interaction, heard staff telling the resident to get up and that she was not handicapped, observed an unsuccessful attempt to stand, and left without reporting the incident. The resident’s representative later reported the abuse with an audio recording capturing the resident crying, screaming, complaining of rough treatment, and begging staff to stop while staff mocked and laughed. RNs, the DON, and a lead CNA who reviewed the recording described the language and tone as cruel, degrading, and malicious, yet the allegation was not reported to the SA within required timeframes, no immediate investigation occurred, and facility administration did not promptly implement protective measures, leading to an Immediate Jeopardy finding under F600.
A resident with severe cognitive impairment, on aspirin and Plavix and ordered for Hoyer lift transfers, fell from bed during ADL care when she pulled herself toward the edge and slipped to the floor. CNAs manually lifted her back to bed without using the mechanical lift and without an LPN or RN present to assess her at the time. Documentation of the fall was delayed and inaccurate, and initial assessment occurred only after bruising was later noted. A hematoma and bruising to the head and shoulder were documented, but neuro checks were not initiated immediately and the provider was not notified when the head injury was first observed. The DON was informed of the fall days later, did not review existing notes documenting the hematoma, and did not physically assess the resident’s head. The provider was eventually notified only of shoulder pain and ordered an X-ray, while the resident continued on antiplatelet therapy until she later developed altered mental status and was transferred to the hospital, where a large subdural hematoma was found.
A resident with severe cognitive impairment sustained a significant burn to the hip/thigh area when another resident handed him hot coffee that spilled, and despite this event, residents continued to have unsupervised access to hot coffee from dining room machines without temperature controls or access restrictions. On a separate night shift, an LPN who appeared impaired—falling asleep at the med cart, crying, moaning, stumbling, and repeatedly going to the bathroom—remained responsible for resident care and medication administration for hours without a designated charge nurse on duty. CNAs reported that residents repeatedly called for their medications, camera footage showed the LPN unable to safely perform duties, and another LPN pulled medications for the impaired nurse without observing administration, verifying correct residents, or documenting on the MAR, while the impaired nurse retained narcotic keys. Medication audits and MAR reviews showed numerous missed and late doses, and cognitively intact residents reported not receiving ordered medications or blood sugar checks, leading surveyors to determine Immediate Jeopardy and substandard quality of care related to abuse/neglect protections.
A cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident while both were seated together in the dining room without staff present. A dietary staff member observed the male resident stroking the female resident’s face and hair, and a CNA then witnessed the breast touching and reported it. The male resident later admitted to the touching and stated he did it because he loved her or to see her reaction, while the female resident, who had dementia and a BIMS score indicating moderate cognitive impairment, was unable to recall the incident. These events occurred despite the facility’s abuse policy stating it would take steps to prevent abuse and neglect.
A cognitively intact male resident inappropriately touched a severely cognitively impaired female resident, including rubbing her thigh and side of her breast while visiting another resident in the same room. The female resident reported telling him to stop, and another cognitively impaired resident in the room reported witnessing the touching in the groin area. A CNA observed the male resident with his hand in the female resident’s brief and his mouth on her breast but did not immediately report the incident, and the ADM did not receive the allegation until several days later, resulting in a failure to protect the resident from sexual abuse and a delay in initiating an investigation.
A male resident with a history of sexually inappropriate behaviors was not placed under supervision or subject to care plan interventions, despite prior incidents. This led to two female residents with severe cognitive impairment being inappropriately touched in the day room on separate occasions. Staff failed to communicate the initial incident, resulting in the resident being left unsupervised and able to reoffend before one-to-one observation was implemented.
A resident with moderate cognitive impairment and hemiplegia was subjected to abuse when a nurse aide pulled the resident from a seated position onto the floor, verbally berated the resident, and sprayed an aerosol substance on the resident's lower body. Multiple staff and the resident confirmed the aide's actions, which resulted in the resident experiencing fear, distress, and compromised dignity.
Two cognitively intact residents reported that an LPN spoke to them in a loud, demeaning, and intimidating manner, with one resident feeling degraded and afraid after a medication-related interaction. Another resident described the LPN as using a rough tone and intimidating residents. Staff interviews confirmed the LPN's negative, vulgar, and insulting behavior towards both residents and staff, including the use of profane language. The facility's policy prohibits abuse, but these incidents demonstrate a failure to prevent verbal abuse.
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