State Findings:
Based on interview, record review, facility document review, and review of the facility’s policy titled,
Prevention of Patient, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the
facility failed to ensure residents were free from physical abuse from Resident (R) (#79) for three of seven
sampled residents reviewed for abuse (R13, R19, and R6). An altercation between R79 and R13 resulted in
actual harm to R13 when he sustained an eyebrow laceration requiring repair and an orbital floor closed
fracture.
Review of the facility’s Incident Report Form, dated 9/9/21 and provided by the facility, revealed On 9/9/21 at
11:50 a.m., [R13] pushed [R79] because he was talking bad about some of the female residents. In the
process of [R79] being pushed, [R79] took a swing and hit [R13] by his eye. [R13] was sent to the ER
[emergency room ] for stitches. Review of the Situation Background Communication Form dated 9/9/21 revealed the physician was notified
that R13 was involved in an altercation with another resident and sustained a laceration above the left eye that may require suturing. Emergency medical transport was initiated.
Review of the Nurse’s Note, dated 12/3/21 at 1:10 p.m. and located in the EMR under the Progress Notes
tab, revealed Resident was involved in altercation in the day room. Resident [R19] was attacked by another
resident [R79] after a verbal altercation. The other resident [R79] punched him [R19] in the head and neck
area several times. He [R19] was knocked out of his wheelchair and landed on the floor on his right side.
Staff assisted resident [R19] off floor. Resident [R19] assessed for pain and injuries. Resident [R19] had a
skin tear to right lower leg. Bleeding stopped, and dressing applied. 911 and MD [Medical Doctor] notified.
[R19’s family] called and aware.
The Nurse Consultant stated the resident was not a good fit for the facility and that he was danger to
himself and others.
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.
If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.