A cognitively impaired resident with a history of stroke and dementia was assaulted by a roommate who had extensive psychiatric diagnoses, a history of domestic violence, substance abuse concerns, and documented episodes of psychosis, threatening behavior, and abusive language. Staff had previously observed this aggressive resident appearing intoxicated, making threats to harm others, rejecting care, and using vulgar and derogatory language, yet his initial care plan did not address his violent and aggressive history, and enhanced monitoring such as q15‑minute checks had been discontinued before the incident. On the day of the assault, CNAs and a nurse found the injured resident with facial bruising, swelling, bleeding from the mouth, and later a diagnosed facial contusion and closed head injury, while the aggressive resident admitted to hitting him. Care plans and the Kardex contained inconsistent and delayed behavioral interventions, and there was no ongoing close observation or 1:1 supervision in place at the time, despite the facility’s policies requiring protection from physical abuse.
A resident with a history of cerebral infarction and malignant neoplasm reported missing funds from a debit card, and facility records and financial documentation showed that a CNA used the resident’s debit card without consent, resulting in $981 in unauthorized charges. The NHA confirmed that the internal investigation identified the CNA as the individual who misused the card, in violation of the facility’s abuse and neglect policy that prohibits misappropriation of resident property.
A resident with progressive MS, neuromuscular bladder dysfunction, and total dependence for ADLs reported that night-shift staff ignored call lights and verbal calls for help, leaving him in a soiled brief for hours and leading him to call 911 multiple times when he could not reach staff by call light or phone. Police and fire reports documented unanswered calls to the facility, staff unaware of the resident’s needs until prompted by first responders, and nurses observed on personal phones before attending to the resident. The resident stated these concerns were ongoing and had been reported to prior administrators and nursing staff, while the current administrator denied knowledge of the complaints, despite a facility policy guaranteeing freedom from abuse and neglect.
A resident with intact cognition and significant medical conditions repeatedly called out for help at night because they could not reach the call light and needed to be turned due to pain. An LPN and CNA delayed responding, told the resident to stop yelling and that they were not the only patient, and refused to turn the resident, stating it had not been two hours and that pain medication had already been given before saying "Goodnight" and leaving. The resident’s continued calls for help were ignored, and when the CNA later re-entered and exited the room, the CNA told the resident that if they became soiled, "that's on you." The resident later reported that the staff were mean and would not help despite their repeated calls.
A resident with impaired cognition and physical weakness was sitting in the lobby when another cognitively impaired resident with a known history of agitation, confrontational behavior, and prior physical altercations followed and began hitting the resident on the head while yelling, as confirmed by the involved resident and a receptionist. The aggressive resident already had a behavior care plan identifying physical threatening behaviors and difficulty with redirection, but no new interventions or updated documentation were added to the behavior care plan or progress notes after this incident, despite the facility’s abuse policy stating residents have the right to be free from abuse and mistreatment.
A resident admitted with stroke, pneumonia, dysphagia, and type 2 DM, and ordered NPO with PEG tube feeding and insulin, experienced neglect when staff changed the ordered Glucerna formula to Jevity without rationale and significantly delayed initiation of tube feeding and water flushes. Facility staff failed to enter and follow discharge insulin orders on admission, did not start oral DM medication and basal insulin until nearly two weeks later, and did not consistently act on repeated BG readings over 300–500+ despite a policy to notify a practitioner for BG >400. Therapy staff and CNAs reported progressive lethargy, weakness, and increased dependence for transfers, while the record lacked nursing assessments of change in condition, respiratory assessments or monitoring for pneumonia, documentation of antibiotic use for pneumonia, or PEG site assessments. EMS later documented that staff reported the resident had been in an altered mental status with BG levels above 500 for several days before transfer, and hospital records showed admission for altered mental status, severe hypernatremia, hyperglycemia, AKI, and sepsis, demonstrating that the resident’s change in condition went unrecognized and undocumented by facility nursing staff.
Failure to Protect Residents from Abuse and Neglect: Staff exchanged profanity with a resident after a request for coffee, residents used derogatory and disparaging language toward each other during bingo, a nurse allegedly failed to timely provide ordered pain medication after repeated call light requests, and two residents were involved in a physical altercation in which one struck the other in the face. The facility later acknowledged verbal abuse, neglect, and physical abuse in its interviews and records.
Two residents were subjected to abuse by nursing staff. In one case, a cognitively intact resident and his roommate reported that an RN, during a night shift interaction about oxygen use, cursed at the resident, stated "I hate you," and made an obscene gesture, which the facility’s own documentation identified as verbal abuse. In the second case, a resident with dementia, chronic pain, anxiety, and a history of pacing and anxiety-related behaviors was confronted by an LPN while she stood at a med cart. Witnesses reported that the LPN escalated the situation, grabbed the resident’s wrists, forced her arms behind her back in a painful position, slammed her into doors, took her into her room amid loud banging and the resident’s cries that she was being hurt and could not breathe, and repeatedly slammed the door on the resident as she tried to exit, while yelling at her and threatening to fight her. The resident was later observed crying, shaken, and disheveled, and reported that the LPN had choked and thrown her down. Facility leadership substantiated that verbal abuse occurred in the first case and verbal and physical abuse occurred in the second, demonstrating a failure to keep residents free from abuse by staff.
A cognitively intact resident with multiple sclerosis and epilepsy reported that another resident, who appeared intoxicated and had an open can of beer, struck her left arm in a day room, with a RN and CNA hearing a slap-like sound and the resident cry out, and the aggressor later admitting he had "smacked" her arm after drinking. In a separate incident, a resident with dementia and cardiac and diabetic conditions became upset over a wallet he insisted was his, and multiple staff witnesses reported that the former NHA raised his voice, got close to the resident, pointed at him, and called him a profane name while the resident was hollering and swearing, with the resident later recalling that cussing words were used toward him.
The facility failed to ensure nurse coverage for a hallway of resident rooms, leading to widespread missed medications and treatments for multiple residents. A resident with CHF and atrial fibrillation did not receive day-shift medications until late evening, and record review showed numerous missed medication doses and treatments for that resident and many others on the same unit. CNAs reported there was no nurse assigned to the hallway, that residents did not receive medications, and that many were in pain when they were changed without pain meds. Staffing records showed no nurse scheduled for the first floor despite a substantial census, and the DON later acknowledged possible miscommunication about nurse assignments and identified extensive missed medications on a facility report, in contrast to the facility’s own abuse/neglect policy defining neglect as failure to provide necessary care and services.
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