Failure to Investigate Resident Elopement Incident
Summary
The facility failed to investigate an alleged incident of neglect involving a resident's elopement. The resident, a male with dementia, major depressive disorder, generalized anxiety disorder, and vision impairments, was found outside the facility in the parking lot. The incident occurred early in the morning, and the resident was discovered by a staff member from the therapy department. Despite the resident's confusion and ambulation without a wheelchair, the facility's Director of Nursing (DON) and Administrator did not consider the incident as elopement and thus did not report or investigate it. The facility's policy requires the identification and investigation of all possible incidents of abuse, neglect, and mistreatment, and mandates reporting within federal timeframes. However, the facility's Abuse Coordinator did not investigate the incident as required. The DON and Administrator both expressed that they did not view the incident as elopement, despite documentation and staff observations indicating otherwise. This oversight could potentially place residents at risk of abuse, neglect, and/or exploitation.
Penalty
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The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
Facility staff did not complete a thorough investigation of an elopement incident involving a resident with dementia and severely impaired cognition. Staff observed the resident exit through a door, go down a ramp, and the resident was then assisted back inside and assessed with no injuries, while the door alarm and a functional wander prevention device were in place. However, the facility’s investigation lacked documented witness names, written statements, or interviews from staff who witnessed or were working during the incident, despite facility policy requiring that witness identities and accounts be obtained and recorded on the incident/accident report.
A resident with dementia and weakness was found on the floor with right leg pain after an unwitnessed incident and was emergently transferred to the hospital. The Day Shift Supervisor interviewed the assigned nurse and two CNAs, who all denied witnessing the fall, but no further interviews or investigative steps were taken to determine how the resident came to be on the floor. Leadership could not provide credible evidence that a thorough investigation was completed, while facility policy required immediate and comprehensive investigation of injuries of unknown source, including expanded staff interviews, written statements, and review of medical records to determine whether abuse occurred and the probable source of the injury.
A resident with severe cognitive impairment and behavioral disturbances became combative during care with a CNA and subsequently had a skin tear on a finger and a contusion with swelling under one eye. The resident later reported to nursing staff that the CNA had hit or punched her, while the CNA stated the skin tear occurred when the resident grabbed her arm and she pulled away, and denied recalling any contact with the resident’s face. Nursing staff documented the facial bruising and swelling, and another nurse noted the CNA was unsure how the facial injury occurred. An internal document suggested the resident hit herself but also acknowledged the resident’s report of being punched. The facility’s investigation did not document whether any facial bruising existed before the incident, did not identify or analyze possible causes of the cheek contusion, and staff interviews did not specifically address the facial injury, resulting in no determination of the probable source of this injury of unknown origin as required by facility policy.
Staff failed to thoroughly investigate an allegation that a cognitively impaired, elopement-risk resident with a wanderguard was found outside the building by a visitor, visibly cold and wearing only a short-sleeved shirt and pants. The visitor reported difficulty reaching staff by phone and stated that a staff member eventually returned the resident inside. Facility leadership initially denied receiving a report, then acknowledged a call but believed the name did not match any resident. Witness statements and a body/skin inspection form were produced with dates that did not align with when staff reported actually giving statements, and some staff denied being asked for statements, resulting in inconsistent and unreliable documentation that did not meet the facility’s own abuse/neglect investigation policy requirements.
Facility staff did not conduct complete investigations into multiple allegations of abuse and misappropriation involving several residents. In one case, a resident with a TBI physically assaulted another resident, but the investigation lacked staff witness statements and failed to identify all individuals present. In another incident, a resident was assaulted in the hallway, yet there was no evidence that residents or staff were interviewed or that all witnesses were identified. Additionally, when a resident reported missing money after a room change, the investigation was limited to a brief summary and did not include staff interviews or efforts to locate the missing funds.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Thoroughly Investigate Resident Elopement Incident
Penalty
Summary
Facility staff failed to complete a thorough investigation of an alleged elopement involving Resident #1. The resident had a diagnosis of dementia and was assessed on the MDS as having severely impaired cognition. An incident form dated 2/11/2025 documented that staff witnessed the resident go out an exit door in the evening, proceed down a ramp, and be observed by staff who were spreading salt on the sidewalks. Staff in the parking lot were advised, and the resident was assisted back into the building and assessed by nursing with no injuries. The facility’s investigation, dated 2/19/2025, documented that the door alarm was sounding as the resident exited and that the resident was wearing a functional wander prevention device at the time. Review of the facility’s investigation revealed that it did not include documented witness statements or interviews from staff who witnessed the event or were working at the time of the incident. The investigation consisted only of an initial report and a summary of findings, without listing staff member names or their accounts. The Administrator confirmed that no written statements or interviews were obtained and that only a phone interview with the maintenance staff member was conducted shortly after the resident was brought back inside. Facility policies on Elopement/Missing Person and Accidents and Incidents – Investigating and Reporting required that the Report of Incident/Accident Form include names of witnesses and their accounts, but this information was not documented in the investigation of this elopement.
Failure to Investigate Injury of Unknown Origin After Unwitnessed Fall and Hospital Transfer
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who required emergent hospital transfer. The resident was admitted with diagnoses including dementia and weakness. An Incident/Accident Report documented that the resident was found lying on the floor, complaining of right leg pain, and that the incident was unwitnessed. The Day Shift Supervisor reported being informed by the Social Services Director that the resident was discovered on the floor and stated she was responsible for follow-up investigation of incident/risk management reports. She interviewed the assigned nurse and two CNAs on the unit, all of whom stated they did not witness the fall. No additional interviews were conducted to determine what led to the resident being found on the floor in pain and then emergently transferred to the hospital. The Executive Vice President/Chief Operating Officer was unable to provide credible evidence to surveyors that a thorough investigation had been completed or to explain the incident. The Chief Clinical Officer stated surveyors were not permitted to review incident/risk management reports, staff statements, or investigative documentation and also did not provide credible evidence that a thorough investigation had been completed. This was inconsistent with the facility’s own policy, which requires the Administrator to immediately begin an investigation of all injuries of unknown source, including interviewing the resident and all witnesses, expanding interviews to prior shifts if there are no direct witnesses, obtaining written statements, and reviewing medical reports and records, and to reach a conclusion regarding whether abuse occurred and the probable source of the injury.
Failure to Thoroughly Investigate Facial Injury Associated With Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a potential injury of unknown origin related to an allegation of abuse for one resident. The resident had dementia with behavioral disturbances, restlessness, agitation, and bipolar disorder, and was severely cognitively impaired with a BIMS score of 3/15. According to the facility-reported incident, the resident became combative and physically and verbally aggressive during care with a CNA at approximately 10:00 PM, during which the resident sustained a skin tear to the right fourth finger and a contusion to the right cheek. The next morning, the resident told the DON that the CNA had grabbed her hand and hit her face, and when the RN assessed the resident after the incident, the resident stated that the CNA had punched her. The RN documented bruising and mild swelling under the right eye at the bony area and noted that the CNA stated she could have hit the resident’s face while the resident was swinging. The facility’s investigation file contained statements from the CNA describing the resident grabbing her arm and swinging, and the CNA pulling back, causing the skin tear from the CNA’s watch, but the CNA denied remembering any contact with the resident’s face. Another nurse documented observing a swollen and discolored right eye and that the CNA did not know how the facial bruising occurred or whether the resident’s own hand hit her face. An undated abatement document stated the resident became combative, sustained a skin tear, and hit herself, causing swelling to the eye, while also noting that the resident had reported being punched in the face. There was no documentation in the investigation file or EMR ruling out or mentioning any pre-existing facial bruising before the incident or exploring possible causes for the cheek contusion. Although all staff on the unit were interviewed, they were not specifically asked about the cheek contusion, and the Administrator and DON later acknowledged they could not determine the exact cause of the facial injury and that the reenactment focused on the skin tear rather than the cheek contusion, contrary to facility policy requiring a determination of the probable source for injuries of unknown origin.
Failure to Thoroughly Investigate Alleged Elopement and Neglect Incident
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of neglect involving a cognitively impaired resident with vascular dementia and diabetes mellitus who was care planned and ordered for elopement precautions, including a wander/elopement alarm (wanderguard) to the right wrist and routine checks of its placement and function. The resident’s MDS showed severe cognitive impairment but clear speech, and the care plan identified the resident as an elopement risk who wandered aimlessly. Physician orders and the treatment administration record documented that wanderguard placement and function checks were completed as ordered. A visitor reported arriving at the facility in the early evening to return laundry and finding the front door locked with no staff at the reception desk, while hearing an alarm sounding inside. After approximately 10 minutes at the door, the visitor observed a resident walking around the outside of the building from the right side, wearing pants and a short-sleeved shirt without a coat and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and the resident responded with his first name. The visitor stated they repeatedly called the facility with no answer, then called 911; the 911 operator reportedly called the facility twice before someone answered, after which a female staff member brought the resident back inside toward Unit 1. The visitor later called the DON the next day to ensure the incident was reported, and the DON stated they would investigate. When surveyors interviewed staff, multiple CNAs and an RN stated they did not recall the resident being outside on the reported date. The ED and DON initially stated no one had called them about the resident being outside; the DON later acknowledged receiving a call but believed the name given did not match any resident. The DON provided witness statements and a body/skin inspection form dated around the time of the alleged incident, but the unit manager (LPN) reported obtaining the statements on a later date and instructed staff to date them for the day of the incident, resulting in discrepancies between the actual date statements were taken and the dates written on them. Some staff named on the witness list either denied giving a statement or reported giving one on a different date than documented. These inconsistencies, along with the lack of clear documentation of the alleged elopement and the facility’s own abuse/neglect policy requiring immediate, documented investigation with timely, signed, and dated statements, demonstrated that the facility did not complete a thorough investigation of the neglect allegation.
Failure to Conduct Thorough Investigations into Abuse and Misappropriation Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple allegations of abuse and misappropriation involving four residents. In one incident, a resident with a traumatic brain injury physically assaulted another resident in the smoking area, resulting in injury. Documentation of the incident was incomplete, lacking details such as staff witness statements and identification of all individuals present. Interviews revealed that no staff were present during the incident, and the assigned staff member for supervision was not interviewed as part of the investigation. The investigation file contained only a single resident witness statement and did not include comprehensive evidence collection or interviews with all potential witnesses. In another case, the same resident assaulted a different resident in the hallway, and there was a lack of evidence that a thorough investigation was conducted. The investigation file did not indicate that either resident or any staff were interviewed, nor were attempts made to identify additional witnesses. Documentation showed that the resident was on one-to-one supervision at the time, but there was no evidence that the assigned staff member was interviewed. The clinical records and incident summaries provided were insufficient to demonstrate a complete investigation into the events. Additionally, a resident reported missing money after being moved to a different room, but the facility failed to provide credible evidence of an investigation. The investigation file contained only an incident summary, a facility synopsis, and a handwritten, undated, and unsigned statement. There was no indication that staff interviews were conducted or that efforts were made to determine if anyone had seen the money prior to the report. The facility's own policies require immediate and thorough internal investigations, including evidence collection and interviews, but these procedures were not followed in the cases reviewed.
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