A resident was subjected to verbal abuse when a CNA used inappropriate language during care, in violation of the facility’s abuse policy that requires residents be free from verbal, mental, sexual, and physical abuse and be treated with respect and dignity. The incident was investigated and determined to meet the facility’s definition of verbal abuse, which includes intimidation or punishment causing mental anguish.
The facility failed to prevent physical abuse when a resident with severe cognitive impairment and a documented history of verbal and physical aggression repeatedly punched another severely cognitively impaired resident in the head while seated in a common area, causing a raised knot on the forehead and requiring hospital evaluation. The aggressive resident had diagnoses including anxiety disorder, schizophrenia, and antisocial personality disorder, and the care plan called for line-of-sight supervision and avoiding the resident’s personal space when agitated. Despite an abuse prevention policy intended to prevent physical abuse, the assault occurred in a shared area and resulted in injury.
A resident with bipolar disorder, borderline personality disorder, and anxiety, who was care planned for demanding behaviors and psychosocial vulnerability, was subjected to verbal abuse by a QMA. During an interaction in which the resident became upset and made threatening statements, the QMA responded by threatening to hit the resident if the resident hit her, stating they would both go to jail. The QMA admitted making this threatening statement, which met the facility’s definition of verbal abuse and violated the resident’s right to be free from abuse.
A bedbound resident with chronic respiratory failure, anxiety, and depression was repeatedly subjected to verbal abuse, cursing, and threats from another resident who lived across the hall and had a documented history of alcohol abuse and aggressive behavior. The aggressor resident frequently stood in the doorway, yelled insults, and threatened to beat the bedbound resident, including during trach care, while staff were present. Staff and the resident’s family reported multiple incidents and expressed safety concerns, including fears that the aggressor, who came and went freely and sometimes returned intoxicated, could bring a weapon into the building. Despite prior documented behavior issues, the facility did not consistently document key altercations, including one requiring police involvement, did not implement a documented behavior contract or safety plan, and leadership minimized the events by asserting that the behavior did not constitute abuse because the victim did not admit psychosocial distress, resulting in ongoing exposure to verbal abuse and intimidation.
A resident with dementia and a history of physical and verbal aggression took adhesive wipe packets from the nurse station and refused to return them despite calm redirection and an offer of a snack from an LPN. An RN observing the interaction approached from behind and sprayed wound cleanser toward the resident’s face without speaking, causing the resident to drop the packets, startle, and wipe his face and eye. A housekeeper witnessed the RN’s actions, and both the LPN and the housekeeper did not immediately report the incident, initially not recognizing it as abuse. The event was later reported to leadership and confirmed on video, and clinical notes documented that the resident had no recollection of the incident and no acute medical concerns.
A facility failed to protect cognitively impaired residents from sexual abuse when a resident with moderate dementia was observed performing oral sex on a resident with severe dementia and a documented history of sexually inappropriate behaviors. The male resident had prior episodes of inappropriate touching, exposure, and agitation when redirected from female peers, and his care plan for inappropriate personal boundaries had been resolved despite ongoing concerns. The female resident had impaired cognition, poor memory, and a care plan that allowed companionship and affectionate contact but did not reflect a formal assessment of her capacity to consent to sexual activity. Staff interviews and records showed that no sexual consent capacity assessment was completed before the incident and that behavior monitoring and interventions for the male resident’s hypersexuality were inconsistent, leading surveyors to cite the facility for failing to protect residents from abuse and to assess and manage sexual behaviors appropriately.
A cognitively intact resident with a history of brain neoplasm, muscle weakness, and depression reported that her roommate, who had bipolar disorder and a documented pattern of escalating behaviors and verbal aggression, became angry over use of a shared landline phone and threatened to kill her and her sister during a phone call. The resident told staff that the roommate kept threatening her, and the sister confirmed hearing explicit death threats, but the DON later characterized the event as only an altercation between the roommate and the sister and did not initiate an abuse investigation or timely report it as abuse. The resident subsequently reported that the roommate continued to intimidate her by walking past her door and making a finger gun gesture, contributing to her staying in her room and avoiding activities, while the SSD acknowledged being told of the gestures but did not interview staff, and the facility’s own abuse policy defining mental/verbal abuse as intimidating conduct was not applied to this situation.
The facility failed to prevent and adequately respond to multiple episodes of resident-to-resident abuse. A resident with schizophrenia and dementia verbally threatened another resident, and the threat was reported to the DON and Social Services, but no effective protective action is described. The next day, the same resident physically grabbed and shoved the threatened resident in the hallway, with staff witnesses describing grabbing by the neck and repeated shoving, while documentation minimized the contact as a slight push. In a related incident, another resident with a history of TBI admitted to pushing her rollator into the same resident’s legs due to perceived intrusion into personal space, after which staff had to separate them. These events occurred amid ongoing reports that the victim resident was pacing halls, entering others’ rooms, and disturbing residents, leading to repeated physical altercations that met the facility’s own definition of abuse.
A resident with dementia and depression, who had severely impaired cognition but could make himself understood, reported that another resident had been mean to him, was bothering him, and had hit him on the head in the dining room, causing him to try to avoid that resident. An incident report documented that one resident struck another on the head with an open hand, with no injuries noted, and an LPN separated the residents after being informed of the event by another resident witness; the aggressor did not deny the action, stating the other resident would not be quiet. Observation later showed the aggressor seated behind the abused resident in the dining room, despite an abuse prevention policy that defines physical abuse as willful infliction of injury, including hitting and slapping.
A CNA used a personal cell phone to record a cognitively impaired resident with dementia, depression, anxiety, and behavioral symptoms while the resident was on a toilet seat riser, exposing the resident’s thigh and calf and verbally addressing the resident by first name as he gripped her wrist. The CNA later stated she recorded the video to document the resident’s behavior and showed it to other CNAs and at least one additional person off-site, despite facility policies prohibiting personal device use in care areas and any photography or video of residents. The resident required maximal assistance with toilet transfers and was frequently incontinent, and representatives reported the resident would have been upset and offended by being recorded in the bathroom, supporting the finding of mental abuse and violation of dignity and privacy.
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