ROCK HILL, SC - Federal inspectors cited Magnolia Manor nursing home for immediate jeopardy violations after investigating allegations that a licensed practical nurse physically abused a cognitively impaired resident with traumatic brain injury.
The January 13, 2025 federal inspection revealed that on November 22, 2024, a licensed practical nurse (LPN1) struck and pushed a vulnerable resident during a confrontational incident that began when the resident returned from a hospital visit. The nurse was terminated on November 27, 2024, following the facility's internal investigation.
Physical Altercation with Vulnerable Resident
The incident involved a resident (R1) who had been admitted to the facility with multiple serious conditions including diffuse traumatic brain injury with loss of consciousness, cervical spine fusion, cognitive communication deficits, and schizophrenia. The resident's cognitive assessment showed severe impairment with a score of 7 out of 15 on standardized testing.
According to witness statements from facility staff, the confrontation escalated when R1 refused to get off a medical transport stretcher upon returning from the hospital. Multiple witnesses reported that LPN1 "automatically started antagonizing" the resident and used excessive force.
A certified nursing assistant who witnessed the incident stated: "LPN1 then pushed [R1] off the stretcher so hard, he almost flew off the stretcher almost onto the floor." The CNA described how the nurse continued to antagonize and belittle the resident throughout the incident.
Escalation to Railroad Tracks
The situation deteriorated further when the agitated resident left the building and walked toward nearby railroad tracks. Witnesses reported that LPN1 followed the resident outside and continued the confrontational behavior despite the resident's vulnerable state and the freezing weather conditions.
According to witness testimony, LPN1 pushed the resident down on the railroad tracks when he became agitated again. "I observed [LPN1] had [R1] by the right arm and then he lost his balance. I saw [LPN1] arm motion, like she pushed him," the witnessing CNA reported. The nurse then prevented other staff from helping the fallen resident get back up.
An ambulance service worker who transported the resident confirmed the physical altercation, stating: "We put him on the bed. [R1] hit [LPN1] hard. Then they started hitting each other multiple times... He was hitting hard, so [LPN1] hit him back."
Medical Vulnerability and Care Requirements
The resident's medical conditions made him particularly vulnerable to injury from physical confrontation. His traumatic brain injury and cognitive impairment affected his ability to process situations rationally, while his cervical spine fusion and unsteady balance created significant fall risks.
The facility's care plan specifically identified the resident as having "unsteady balance and gait" with documented fall risks. The plan required staff to encourage the resident to "assume a standing position slowly" and utilize assistive devices for mobility. The documented approach emphasized providing "reassurance and positive reinforcement for acceptable behavior" rather than confrontational methods.
Residents with traumatic brain injury often experience behavioral changes including agitation, confusion, and difficulty with emotional regulation. These symptoms require specialized de-escalation techniques and patience from caregivers. Physical confrontation can worsen symptoms and create additional safety risks for individuals with compromised balance and cognitive function.
Proper De-escalation Protocols
Standard nursing protocols for agitated residents with cognitive impairment emphasize verbal de-escalation, environmental modifications, and removal of triggers. Physical force should only be used as a last resort to prevent immediate harm, and trained personnel should implement approved restraint techniques when necessary.
The facility's own policies prohibited physical abuse and required adequate supervision to prevent inappropriate behaviors including "rough handling" and "ignoring the patient's/resident's needs." The policies specifically outlined that staff should provide "reassurance and positive reinforcement" for residents with behavioral challenges.
Professional nursing standards require assessment of underlying causes for behavioral changes, such as pain, medication effects, or environmental stressors. When residents become agitated after medical procedures or hospital visits, staff should recognize this as a common response requiring supportive intervention rather than confrontation.
Investigation and Immediate Response
The facility's administrator and director of nursing conducted an immediate investigation following reports of the incident. The investigation included interviews with multiple witnesses and review of documentation. LPN1 was suspended pending investigation and ultimately terminated for "gross misconduct" and "violation of rules/policy."
A police report was filed documenting assault and battery charges. The facility reported the incident to state agencies as required and implemented immediate protective measures for all residents.
The facility conducted body audits on residents to check for signs of abuse and interviewed alert residents about their safety concerns. No additional instances of abuse were identified during the investigation.
Systemic Monitoring and Prevention
Federal inspectors required the facility to implement enhanced monitoring protocols including direct observation of resident care three times weekly by nursing leadership. The facility also instituted random resident interviews to assess safety concerns and feelings of security.
All staff received mandatory re-education on abuse prevention policies, including proper identification of abuse situations and appropriate reporting procedures. The training emphasized immediate removal of alleged perpetrators and comprehensive assessment of affected residents.
The facility's Quality Assurance committee now reviews monitoring results monthly to identify potential patterns or concerns. Any identified issues must be addressed immediately upon discovery.
Regulatory Violations and Oversight
The immediate jeopardy citation represents the most serious level of regulatory violation, indicating that the facility's practices created imminent danger to resident health and safety. This designation requires immediate correction and can result in termination from Medicare and Medicaid programs if not properly addressed.
Federal regulations require nursing homes to protect residents from abuse and provide care that maintains dignity and respect. Facilities must ensure adequate supervision of staff and implement policies that prevent inappropriate behaviors toward vulnerable residents.
The incident highlights the critical importance of proper staff training and supervision in facilities serving residents with cognitive impairments and behavioral challenges. Vulnerable populations require specialized approaches that prioritize safety and therapeutic intervention over confrontational responses.
Magnolia Manor's immediate jeopardy removal plan was accepted by federal inspectors, indicating that corrective measures addressed the identified safety concerns and reduced risks to current residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor - Rock Hill from 2025-01-13 including all violations, facility responses, and corrective action plans.
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