A severely cognitively impaired resident with Alzheimer’s disease, who required assistance with ADLs and had known combative behaviors during care, became agitated and resistive while two NAs were providing incontinence care and dressing. One NA reported that the other NA responded to the resident’s attempts to bite and swing by striking the resident three times with an open hand—once on the lips, once on the cheek, and once on the back of the head—while telling the resident she would not be allowed to hit or bite staff. The reporting NA continued care after the first strike, did not immediately remove the other NA from the room, and only reported the incident after completing the transfer, resulting in a failure to protect the resident from staff-to-resident physical abuse.
A resident with severe cognitive impairment and bowel/bladder incontinence, who required extensive assistance with toilet hygiene, had their call light intentionally disconnected by a NA during an overnight shift to stop repeated call light use. The NA removed the call cord from the wall and inserted a plastic fork into the socket, later providing incontinence care but failing to reconnect the call light. On the next shift, another NA heard the resident yelling, found the fork in the call light socket, and discovered the resident soiled with urine and feces, confirming the resident had been left without the ability to summon assistance.
A resident with dementia and a history of physical aggression toward others repeatedly struck other residents, including one cognitively impaired resident at the nurses’ station, a cognitively intact roommate during a dispute over television volume, and another severely cognitively impaired resident who approached too closely, even while the aggressive resident was on 1:1 supervision. Care plans for the involved residents documented behavioral symptoms, mood disturbances, and wandering, and called for monitoring for aggression, removal from triggering environments, and diversion. However, staff at the nurses’ station were unable to separate residents in time to prevent a slap, the assault with a reaching device in a shared room was unwitnessed, and NAs assigned to 1:1 supervision reported they were not informed of the aggressive resident’s specific triggers or the reasons for the 1:1, contributing to the failure to prevent these resident-to-resident abuse incidents.
A cognitively intact resident with bipolar disorder, schizophrenia, and a documented history of aggression repeatedly physically abused other residents when they entered or altered his environment. A severely cognitively impaired, wheelchair‑bound resident with Alzheimer’s dementia twice wandered into his room and, on each occasion, was struck in the face, resulting in a bruised, swollen, and lacerated lip, swelling to the jaw, and swelling and bruising around the eyebrow. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after using his call light to request a temperature change, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body, leaving him feeling unsafe and victimized. The psychiatric NP and Medical Director acknowledged that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or changed his environment.
A resident who was cognitively intact and independently mobile in a wheelchair was verbally abused and threatened by a housekeeper, who used profane and racially charged language and physically pushed her cart into the resident's wheelchair. Multiple staff witnessed the incident, intervened to separate the individuals, and confirmed the abusive behavior, which was substantiated by the facility's investigation.
A nurse failed to administer prescribed as-needed pain medication to a cognitively impaired resident with chronic pain after the resident exhibited combative behaviors, including spitting. Instead of attempting to calm or reapproach the resident, the nurse left the room, wasted the medication, and did not reassess or attempt to provide pain relief later in the shift. Facility leadership confirmed this constituted neglect.
Two NAs refused to provide transfer and incontinence care to a dependent, cognitively intact resident after a disagreement, leaving her in a soiled brief and wheelchair for several hours in a semi-private room. The resident was found distressed and humiliated, with care only provided after a shift change.
A resident with severe cognitive and behavioral impairments was found with unexplained facial injuries, including swelling and hematoma, after staff failed to observe or report any incident during the previous shift. The resident, who had a history of aggression, named a staff member as the perpetrator, but details were inconsistent and the cause of injury could not be determined. Medical and law enforcement investigations were inconclusive, and the facility did not ensure proper protection or timely reporting of the injury.
A cognitively impaired, nonverbal resident dependent on staff for all ADLs was kicked multiple times by another resident with a history of aggression. The incident occurred in a hallway and was witnessed by a NA, who intervened and reported the event. Staff interviews confirmed the aggressive behavior and the vulnerable status of the resident who was kicked, highlighting a failure to protect residents from abuse.
A resident with intact cognition struck another resident with moderately impaired cognition in the dining room, resulting in a facial bruise. The altercation began after one resident attempted to help the other, leading to verbal abuse and a physical slap, despite staff intervention. The incident was witnessed by the ADON and resulted in police involvement.
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