Failure to protect a resident from physical abuse occurred when two cognitively intact residents had an escalating dispute over a loud TV and one resident entered the other’s room. The interaction turned physical, resulting in a bloody nose for the resident with hearing impairment and anticoagulant use. Both residents later described the event as a misunderstanding, but staff confirmed the resident was struck in the face during the altercation.
A resident with severe cognitive impairment, a history of sexual assault trauma, and a care plan noting preference for female staff was sexually abused by another cognitively impaired resident who had alcohol-induced persisting dementia, high-risk heterosexual behavior, and a documented history of sexual behaviors toward female residents. The second resident’s care plan required supervision around female residents, redirection of sexual behaviors, and intermittent 1:1 supervision after incidents, yet clinical records showed multiple prior sexually inappropriate incidents without evidence that 1:1 supervision was implemented. Staff reported that this resident was not to be alone with female residents, but the staffing coordinator observed the resident in a common area with a hand under the other resident’s shirt, fondling the breast while the victim tried to push the hands away, with no other staff present.
A hospice resident with COPD exacerbation and respiratory failure had PRN orders for oral morphine for SOB and moderate to severe pain but, according to multiple staff interviews and record review, an LPN refused to administer the ordered morphine during a period when the resident was screaming, anxious, disoriented, and exhibiting terminal agitation and SOB. Staff reported that the LPN declined to medicate the resident due to concern about depressing respirations, would not call hospice or the physician, and refused to provide the med cart keys to another LPN who attempted to follow the physician’s orders. CNAs and another LPN described the resident as having a very bad night with ongoing pain and distress, while the hospice care manager noted frustration with ordered medications not being administered and confirmed morphine was appropriate for the resident’s symptoms.
Two residents, both cognitively intact but with significant medical histories, were involved in a physical altercation after one resident threatened to harm the other. Despite a request for a room change and intensified monitoring, the facility did not follow its policy for urgent relocation, resulting in one resident physically assaulting the other and both requiring hospital care.
Two residents, one with chronic pain and another with Alzheimer's disease, were subjected to verbal abuse and derogatory remarks by another resident. Staff and the DNS confirmed the inappropriate behavior, which included profanity, name-calling, and offensive comments, but the facility failed to prevent or adequately address these incidents.
Two residents, one with moderate cognitive impairment and another cognitively intact, were involved in intimate contact observed by staff. Despite the incident, staff did not promptly assess both individuals for their ability to consent or confirm the interaction was consensual, allowing them to remain together without proper evaluation.
A resident with severe cognitive impairment was found in another resident's room engaged in inappropriate sexual contact, with no memory of the event and exhibiting unusual behavior afterward. Despite the incident and the other resident's history of inappropriate conduct, the facility did not implement or document any interventions to ensure safety, and the family was not promptly notified.
A resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping, resulting in the catheter tubing being forcibly removed and causing severe pain. Staff and the resident confirmed the incident led to significant distress and ongoing discomfort, with multiple CNAs witnessing the aftermath and providing support.
A resident with cognitive impairment and a history of aggressive behaviors entered another resident's room and physically abused them, resulting in bruising. The facility failed to implement adequate monitoring or preventive measures to protect residents from such interactions, leading to a substantiated case of abuse.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
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