Failure to Prevent Neglect Due to Inadequate Staffing and Improper Transfers
Summary
The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing sufficient, qualified staff and by allowing untrained aides to perform transfers and incontinence care alone, contrary to the facility assessment, policies, and care plans. Timecard review showed that on 34 of 84 shifts between early January and mid-February, only one direct care staff member was on duty, despite the facility assessment requiring at least two direct care staff and one nurse per shift when residents required mechanical lifts or two-person transfers. The AIT and ADON both acknowledged ongoing staffing shortages, frequent no-shows, and that resident care suffered because the facility was short staffed. The AIT stated it was not safe to have only one aide working on the floor and that policies requiring two staff for transfers and incontinent care were not always followed. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff and a mechanical lift for transfers was dropped during a mechanical lift transfer performed by a single aide who was not certified and had no documented training or abuse/neglect education. The resident reported being dropped to the floor, then pulled back into the wheelchair and told not to report the fall; her roommate, who had moderate cognitive impairment, stated she saw the aide alone with the lift, heard the aide exclaim, and observed the resident and lift on the floor. The resident was later found dragging her leg, reported pain, and was hospitalized with a distal femur fracture requiring surgery. The aide later stated she had not been trained on mechanical lift use and denied transferring the resident alone, while another aide and a nurse gave conflicting accounts and denied assisting with the transfer. Another resident with severe cognitive impairment and a care plan requiring two-person mechanical lift transfers was observed being transferred by a single aide using a stand-and-pivot method without a mechanical lift. The aide admitted she was the only aide working, knew the resident required a mechanical lift and two staff, and stated she routinely transferred the resident this way because no help was available. A third resident, with moderate cognitive impairment and high fall risk, required prompt response to call lights and assistance with transfers and toileting. She activated her call light to request help to the restroom, but no staff were present in the hall or at the nurses’ station; after waiting, she attempted to go alone, urinated on herself, slipped, and was found on the floor by a hospice aide while the call light was still engaged. The AIT confirmed that only one aide was on duty that shift, that staff no-shows were common, and did not explain why she and the ADON, who were in the office, did not answer call lights. A fourth resident with moderate cognitive impairment, colon cancer, muscle weakness, and a high fall risk had multiple falls over several weeks, including two falls on the same day that resulted in rib fractures, pleural effusion, and hospitalization, and another fall causing a forehead injury. Progress notes documented repeated falls related to attempts to transfer or reach items independently, and the resident’s representative reported the resident was anxious and tried to get up on her own. The care plan for falls had not been updated with new interventions since several months prior, despite the series of falls. Timecards showed that during at least two of the resident’s falls, only one direct care staff member was on duty. A fifth resident with severe cognitive impairment, depression, anxiety, mixed bladder incontinence, and a care plan requiring staff assistance for toileting and checks/changes every two hours was left in wet clothing for approximately two hours after requesting help. She first asked the only aide on duty, who told her she was too busy. The resident was later observed crying in the hall and then sitting in the dining room with visibly wet pants. When she asked an RN to change her, the RN looked at her but did not acknowledge the request. The resident became upset and attempted to remove her wet clothes in the dining room, after which the ADON reprimanded her and told her to go to her room. She was not assisted with changing until about two hours after her initial request. The aide later stated she was working alone, was very busy, and acknowledged that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Personnel file reviews showed that aides designated as nurse aides were not certified and lacked documented training, including mechanical lift training and, in at least one case, abuse/neglect training. The facility’s policies required two staff for mechanical lift transfers and prohibited aides from performing transfers and incontinent care alone, and the facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The MD stated his expectation that residents be free from abuse and neglect, that policies be followed, and that residents’ needs be met by staff with the knowledge and skills to provide necessary care, and he confirmed that being dropped from a mechanical lift could cause the type of femur fracture sustained by one resident and that not following transfer policies could have led to injury for another resident. An Immediate Jeopardy situation was identified related to these failures.
Removal Plan
- Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; if there are any mechanical lift residents, ensure a total of one LVN/RN and two direct care staff are in the building at all times; assess staffing requirements weekly based on census and resident needs; maintain two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
- Ensure DON and ADON verify that all agency or temporary direct care staff have documented training/credentials prior to working a shift (including checking the agency portal and obtaining CNA credentials from the sister facility) and ongoing.
- Assess Residents #5, #3, #2, and #16 for any further injury, pain, or emotional distress.
- Report Resident #1's fall to the state agency per reporting requirements.
- Assess and monitor Resident #1 for negative outcomes.
- Remove NA-A from resident care pending investigation.
- Complete investigation of the incident by AIT.
- Terminate NA-A as disciplinary action.
- Create an informational handout for incident reporting and mechanical lift use and review it.
- Provide an instructional mechanical lift demonstration for all staff by the facility's COTA.
- Review incidents within the last 30 days to identify other residents at risk.
- Re-educate all direct care nursing staff on shift on abuse/neglect policy (including safe transfer procedures and supervision expectations) with a signature sheet; require review for all direct care staff before start of first shift.
- Provide abuse/neglect and related education at an in-service with a signature page.
- Ensure the agency and sister facility only send CNAs.
- Require the charge nurse to verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse/neglect during shift report prior to the aide starting the shift; require verbal return instruction to determine competency.
- Re-educate all residents about their rights, abuse, neglect, and reporting.
- Review abuse, neglect, transfers, and reporting upon hire; provide monthly review at mandatory in-service; provide one-on-one education annually at staff hire anniversary; enforce that any violations of policy will result in termination.
- Require the charge nurse to initial, date, and log the name of each agency and sister facility staff member educated.
- Complete a mandatory all-staff in-service reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect.
- Reinforce expectation that violations of abuse/neglect, mechanical lift, and reporting policies will result in disciplinary action up to and including immediate termination.
- Train all staff on falls and call light usage via phone calls with return instruction to ensure retention of information; prevent staff who do not answer the phone from returning to work until retrained; maintain a DON log of staff contacted and educated.
- Have DON/designee review all incidents daily for 30 days to establish a risk-of-incident analysis based on patterns of staffing and incidents.
- Conduct a monthly abuse/neglect audit for direct care staff and incidents and report to QAPI for 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Abuse During Incontinent Care: A CNA was observed on video using forceful and aggressive handling while providing incontinent care to a resident with severe cognitive impairment and total ADL dependence. The resident yelled, moaned, and repeatedly asked what he had done while the CNA grabbed his wrists, turned him forcefully, held him down, and moved his limbs without speaking. Later, the resident told staff and family that a tall man had entered his room, held him down, and hit him, and the CNA admitted he had gotten rough and restrained the resident during care.
A resident with severe cognitive impairment and a history of combative behavior during care was being assisted by two CNAs with incontinence care when the resident became resistive and kicked one CNA in the leg. Instead of following the care plan directive to stop care and return later when the resident was physically abusive, the CNA immediately retaliated by open-handedly slapping the resident hard in the face, causing visible redness and leaving the resident appearing stunned and fearful. The second CNA, who witnessed the slap, briefly left the room to report the incident to the nurse, leaving the resident alone with the CNA who had just abused him, thereby failing to ensure the resident’s immediate protection from further abuse.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
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.
A resident with a history of TBI, anxiety, and mild neurocognitive disorder became agitated after staff moved a wheelchair he had positioned to avoid blocking his window view, leading to escalating verbal aggression toward staff. Witnesses reported that when the resident approached the nurses’ station with clenched fists and swung at an RN, the RN grabbed the resident’s arm and/or shoulder and took him to the floor, then restrained him there until supervisors arrived. Immediately afterward, the resident complained of severe left hip pain, with clinical signs of injury, and hospital evaluation confirmed a left comminuted displaced intertrochanteric fracture requiring surgical repair. Multiple staff later stated that they are not allowed to restrain residents and would instead use de-escalation, walk away, or call for assistance when residents are aggressive, while the DON acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm.
A resident with quadriplegia and intact cognition, care planned and documented as requiring a two-person assist for bed mobility, was being checked by a NA who knew another aide was supposed to assist. The NA rolled the resident toward herself, noted a bowel movement, and turned away to look for supplies while waiting for help, despite the two-person assist requirement. During this time, the resident slid off the bed to the floor. She was initially assessed with only redness to the upper back but complained of increased left leg pain, and was later transferred to the hospital, where she was found to have a left femoral neck fracture. Facility investigation determined the NA failed to follow the care plan and Kardex instructions for two-person bed mobility, and the NHA and DON substantiated neglect during care.
Abuse During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA used forceful and aggressive handling during incontinent care. The resident was a male with severe cognitive impairment, including a BIMS score of 0, and diagnoses that included heart failure, hypertension, end stage renal disease, Alzheimer's disease, stroke, and non-Alzheimer's dementia. He was dependent for ADLs and required assistance from one staff member for care. During the early morning care episode, video footage showed the CNA entering the resident's room, turning on the light, removing the covers, and then grabbing the resident's wrists and forcefully turning him onto his side while removing the brief. The CNA placed his weight on the resident's shoulder, then later pushed the resident to the opposite side, grabbed the resident's wrist again, and forcefully yanked him over while the resident yelled and moaned in distress. The footage also showed the CNA crossing the resident's wrists over his chest, holding him down while adjusting the brief, and grabbing the resident's ankles and moving them toward the center of the bed. Throughout the incident, the CNA did not speak to the resident, and the resident repeatedly asked what he had done. Later that morning, the resident told staff and family that a tall man had entered his room during the night, held him down, and hit him on the face. He said he felt fearful and did not want that man in his room again. Staff who interviewed the resident reported that his account remained consistent, and multiple staff stated the resident had not been combative during care and had not previously made similar allegations. The CNA acknowledged that he had gotten rough with the resident, restrained him while putting on the brief, and admitted he probably should have stopped when the resident was yelling and asking him to stop.
Resident Physically Abused by CNA and Left Unprotected After Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to ensure immediate protection from further abuse once an incident occurred. An elderly male resident with heart failure, unspecified dementia with agitation and other behaviors, and Alzheimer’s disease was admitted to the facility and had a BIMS score of 0, indicating severe cognitive impairment. His care plan documented impaired cognitive function and a history of becoming combative with staff at times, with interventions directing staff not to attempt care when he was physically abusive and to allow time and revisit the task later. Despite these documented needs and interventions, the resident was subjected to physical abuse by a CNA during routine care. On the day of the incident, two CNAs entered the resident’s room to perform routine rounds and provide incontinence care while he was in bed. According to statements and interviews, the resident was awakened, his clothing and brief were removed, and as care proceeded he became resistive and combative. The resident swung and kicked, striking one CNA on the leg. In response, that CNA immediately and open-handedly slapped the resident in the face/forehead. The slap was described by the witnessing CNA as very hard, leaving the left side of the resident’s face a little red and causing the resident to appear stunned, frozen, and nervous, as if afraid to move. The CNA who slapped the resident admitted in her written and verbal statements that she hit him back after he kicked her leg, characterizing it as a reaction. The facility also failed to ensure the resident was protected from further abuse at the time of the incident. After witnessing the slap, the second CNA briefly left the room to notify the nurse, leaving the resident alone with the CNA who had just physically abused him. During this interval, the abusive CNA remained in the room with the resident, and there is no indication that the resident was immediately removed from the abuser or that the abuser was immediately removed from the resident’s presence before the witness left to report the event. This sequence of actions and inactions—failure to follow the resident’s care plan for managing combative behavior, the CNA’s retaliatory slap, and the witness CNA’s decision to leave the resident alone with the abuser—constituted the failure to ensure the resident was free from abuse and protected from further abuse.
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Resident From Physical Abuse Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse when a registered nurse (RN) took the resident to the floor during an altercation, resulting in a left comminuted displaced intertrochanteric hip fracture that required surgery. Facility policy on "Abuse: Protection From" stated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property, and that residents must not be subjected to abuse by anyone, including staff. The resident involved had a history of traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance, but was assessed as cognitively intact with a BIMS score of 13. On the evening of the incident, the resident became agitated after staff moved a wheelchair that he had positioned to avoid blocking his window view, and he began yelling and cursing at a nurse aide (NA) about the wheelchair placement. According to multiple staff statements and nursing documentation, the resident paced in his room, continued yelling, and then left the room to go to the bathroom. After several minutes, he approached the nursing station, yelling and threatening the RN, with witnesses reporting that he had his fists clenched and was swinging at the nurse. The RN reported that when the resident swung at him, he grabbed the resident’s arm and/or shoulder and took him down or assisted him to the floor, then restrained him there until supervisors arrived. Witnesses, including NAs and another RN, consistently described the nurse catching the resident’s swing by the forearm or grabbing his shoulder/arm and putting or sitting him down on the floor, after which the resident was observed lying on his right side in front of the elevator, screaming in pain and holding his left hip. Following the takedown, staff observed that the resident complained of 10/10 left hip pain, with the left leg shortened and externally rotated. The resident told staff and later hospital providers that the nurse had “tackled” him to the floor. Hospital records documented that the resident reported being tackled after an altercation about moving a wheelchair to see the sunset, and confirmed a left comminuted displaced intertrochanteric fracture requiring orthopedic surgical intervention. In subsequent staff interviews, multiple nurses and NAs stated that facility practice when a resident exhibits aggressive behavior is to walk away, call for help or a supervisor, attempt de-escalation, remove triggers, and that they are not allowed to restrain residents or hold them to the ground. The Director of Nursing acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm in the form of the hip fracture. The deficiency was cited under multiple Pennsylvania regulatory provisions, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 201.18(b)(1)(3) Management, 201.29(a)(c)(d)(j) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3) Nursing services. These citations reflect that the resident’s right to be free from abuse and the facility’s obligations regarding resident care policies and nursing services were not upheld in this incident, as evidenced by the RN’s physical handling of the resident that led to a serious injury.
Neglect During Bed Mobility Leading to Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during bed mobility care, resulting in a left femoral neck fracture. The resident had diagnoses including quadriplegia, gastroesophageal reflux disease, and hyperlipidemia, and was assessed as cognitively intact with a BIMS score of 15. The resident’s MDS and care plan documented that she was dependent for mobility and required assistance of two staff for bed mobility. The Kardex and care plan both specified a two-person assist for bed mobility due to her functional limitations. On the day of the incident, a nurse aide entered the resident’s room to check on her and was aware that another aide would be coming shortly to assist. Despite the documented requirement for two-person assistance, the aide rolled the resident toward herself and noted a bowel movement, then turned away to look for a towel or other item to begin care while waiting for help. During this time, the resident slid off the side of the bed and onto the floor. The aide reported that the resident slid off in such a way that there was no way to catch her, and immediately scanned the resident for obvious wounds or bleeding before finding a nurse to perform an assessment. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with her legs straight out and her head supported on a pillow against the mattress. Initial assessment noted no visible injuries other than redness to the left upper back, and the resident was assisted back to bed with a Hoyer lift and three staff. The resident complained of increased pain to the left leg, and the physician was notified with orders for x‑rays. Later, the resident was transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and the hospital reported that she had sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex and care plan instructions for required two-person bed mobility assistance, and the allegation of neglect was substantiated by the NHA and DON.
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