A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
A resident sustained a leg fracture after being pushed to the ground by another resident in the smoking area following an altercation in which water was poured on one resident. Staff found the injured resident on the ground, yelling in pain and unable to get up, and hospital x‑rays confirmed a leg fracture. The resident who pushed had bipolar disorder, PTSD, depression, anxiety, and moderate cognitive impairment, yet their care plan did not identify behaviors or include a behavior care plan, despite facility policy requiring assessment and care plan interventions for residents at risk of abusing others. An LPN acknowledged that a behavior care plan should have been in place, while the administrator reported that the injured resident was considered the aggressor and that the other resident was generally not a problem unless unable to smoke.
A cognitively intact resident with paraplegia and an indwelling urinary catheter reported that when they approached an RN to discuss concerns about their catheter bag, the RN became angry, stated they did not care, and directed the resident to speak with someone else, causing the resident embarrassment and prompting them to return to their room. The facility’s abuse prevention policy required protection of residents from abuse by anyone, yet interviews and a grievance investigation confirmed that the RN had been verbally aggressive, including hollering and cursing, resulting in a substantiated finding of verbal abuse.
Multiple cognitively impaired residents experienced abuse or suspected abuse when one resident was found on the floor in a room with another resident pulling at their pants and partially exposing their underwear behind a makeshift barricade; in a separate case, a resident who was usually cheerful became tense and frightened, later found with fingertip‑sized bruises and crescent‑shaped skin tears after a CMA overheard two CNAs speaking about the resident in a derogatory manner; and in another incident, a CNA reported seeing a coworker strike a resident’s arm/hand several times after being hit by the resident, while the accused CNA described the contact as tapping in response to being grabbed, all occurring despite an abuse‑prevention policy.
A resident with dementia, mood and conduct disorders, and a history of aggressive and verbally abusive behaviors, including racial slurs, was involved in an altercation with a CNA in a common area. After the resident threw a soda or drink toward the CNA, the CNA immediately retaliated by throwing the drink or can back into the resident’s face and then walked away using explicit language about the resident. Witness statements, the incident report, and the resident’s documented behavioral history showed that the staff member’s retaliatory action constituted abuse, demonstrating a failure to protect the resident from staff abuse as required by facility policy.
A cognitively intact resident, independent in dressing, transfers, and toileting, reported that a CNA entered the room after a late-night shower, remained there for an extended period, and engaged in oral sex and attempted intercourse, which the resident described as not forced but initiated by the CNA. The resident consistently repeated this account to the DON, administrator, and APS, including details of the CNA touching the resident’s chest, placing the resident’s hand on his genital area, exposing himself, and then receiving oral sex followed by an attempted sexual act. Staff statements supported that the CNA was in the resident’s room for an unusually long time, was unaccounted for elsewhere on the unit, and was providing care on a hall to which he was not assigned. The facility substantiated the allegation of sexual abuse, demonstrating a failure to protect the resident from sexual abuse by staff.
A resident with severe cognitive impairment and a history of needing assistance with ADLs reported that another resident had grabbed their breast. The alleged perpetrator had moderate cognitive impairment, multiple medical diagnoses, and a care plan noting behavioral symptoms and a history of socially inappropriate or disruptive behavior, including approaches such as maintaining distance from other residents and intervening to ensure others felt safe. Despite this, video footage later confirmed that this resident moved their wheelchair beside the cognitively impaired resident, lifted the resident’s blanket, and placed a hand on the resident’s breast, showing the facility failed to prevent an incident of resident-to-resident sexual abuse.
Two residents were involved in separate resident-on-resident altercations in which one resident was struck on the head and another had their glasses knocked off, with both victims assessed as having no injuries. The aggressors and victims had differing cognitive statuses, including severe cognitive impairment, moderate cognitive impairment, Alzheimer’s disease, and intact cognition. CNAs witnessed both incidents, one of which was captured on camera, and the events were documented on incident reports and in nursing notes. Interviews with an LPN and the DON described that some residents were placed in memory care due to family concerns about confusion and elopement, and that behavioral concerns and resident altercations were ongoing topics of attention.
A resident with cognitive impairment and behavioral challenges was physically restrained and verbally antagonized by an agency CNA during care, despite objections from other staff. The CNA pinned the resident's arms behind their back, dragged them to a chair, squeezed their wrist, and encouraged the resident to strike staff. The resident expressed pain and distress during the incident, which was witnessed and reported by other CNAs. The DON confirmed the abusive actions and noted missing orientation documentation for the agency CNA.
A cognitively intact resident with multiple medical conditions was subjected to sexual abuse by a CNA who was unaccounted for during their shift and provided care in an unassigned area. The facility failed to prevent unauthorized staff access and did not adequately supervise staff, resulting in a substantiated incident of sexual abuse.
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