The incident at Fleshers Fairview Health Care went unreported for hours. NA #12 witnessed Staff #13 strike Resident #44 but didn't immediately tell supervisors. Instead, she mentioned it the next morning to Nurse #13, who then reported it to the Director of Nursing at 9:37 AM on May 29th.
The delay meant nearly 12 hours passed before administrators learned a staff member had hit a resident.
Resident #44 has a documented history of combative behavior during personal care. Multiple nursing assistants described her pattern of hitting, kicking, and screaming when staff help her dress or provide other care. NA #16 explained that the resident "could be combative and would hit, kick, and scream during care."
Staff developed strategies to manage her resistance. They talk to her during care, offer reassurance, and try to divert her attention. When she becomes combative, they give her a 15-minute break before returning to see if her mood has improved.
NA #15 said these techniques "usually worked to keep her calm during care."
But on the evening of May 28th, those de-escalation methods apparently failed.
The Director of Nursing interviewed NA #12 by phone about what she witnessed. NA #12 said she and Staff #13 were providing care to Resident #44 when the patient became "resistive to care." The DON noted that NA #12 didn't specify what type of care they were providing or what time the incident occurred.
NA #12 told the DON that Staff #13 became upset because Resident #44 was being resistive. The witness didn't describe exactly what the resident did to upset Staff #13, only that she was resisting care.
That's when Staff #13 slapped Resident #44's hand.
NA #12 described the slap as "open handed." She heard Staff #13 tell the resident: "Stop you're not going to treat me like that."
The Administrator said Staff #13 admitted to hitting Resident #44 during a subsequent interview about the incident. The facility substantiated the abuse allegation and terminated Staff #13.
The Administrator reported Staff #13 to health care personnel investigations, a state database that tracks disciplinary actions against healthcare workers.
But questions remain about the facility's response timeline and investigation procedures. The DON said she "was not sure she asked" NA #12 about the specific time the incident occurred. This basic detail could have helped administrators understand exactly when the abuse happened and how long it went unreported.
The inspection report doesn't indicate whether administrators interviewed other staff members who might have witnessed the incident or reviewed security footage if available. It also doesn't specify whether the facility conducted additional training for staff on managing combative residents after the incident.
Resident #44's combative behavior appears to be an ongoing challenge for multiple nursing assistants. The inspection found that several staff members had developed individual approaches to managing her resistance during care.
The incident highlights the difficulty nursing home workers face when caring for residents with behavioral issues. While combative behavior can be frustrating and even dangerous for staff, federal regulations prohibit any form of physical retaliation or punishment.
The facility's termination of Staff #13 and report to state investigators suggests administrators took the abuse allegation seriously once they learned about it. However, the nearly 12-hour delay in reporting raises concerns about whether staff understand their obligation to immediately report suspected abuse.
Federal nursing home regulations require facilities to ensure all alleged violations involving abuse are immediately reported to the administrator. Staff members who witness potential abuse must report it right away, not wait until the next convenient opportunity.
The incident also underscores the importance of proper training in managing residents with behavioral challenges. Effective de-escalation techniques, as described by other nursing assistants caring for Resident #44, can often prevent situations from escalating to the point where staff feel frustrated enough to act inappropriately.
NA #15 and NA #16 demonstrated that it's possible to provide care to combative residents without resorting to physical force. Their approach of talking to the resident, providing reassurance, and taking breaks when needed offers a model for how to handle difficult situations professionally.
The inspection found the facility violated federal standards for protecting residents from abuse. Inspectors cited minimal harm with the potential for actual harm, affecting few residents.
Staff #13's termination removes an immediate threat to resident safety. But the incident exposed gaps in the facility's abuse prevention and reporting systems that could affect other vulnerable residents in the future.
Resident #44 continues to receive care at the facility, still requiring the patient approach that other nursing assistants have successfully used to manage her combative episodes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fleshers Fairview Health Care from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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