Failure to Implement Abuse Policy Leads to Resident's Privacy Violation
Summary
The facility failed to effectively implement its abuse policy, resulting in a situation of abuse when a CNA took a video of a resident during personal care and posted it on social media. The video showed the resident, who had Alzheimer's disease, in a vulnerable state with her bare body exposed and fecal matter on the floor. The facility initially concluded the incident was unsubstantiated because the resident was unaware of the incident, despite the reasonable person concept indicating that any reasonable person would have suffered serious mental or emotional harm from such a video being taken and shared. The resident involved had severe cognitive impairment and was dependent on staff for personal care due to Alzheimer's disease and other conditions. On the day of the incident, the resident experienced incontinence and was taken to the shower room for cleaning. During this time, the CNA recorded the resident and shared the video on Snapchat, which was later reported to the facility by an anonymous caller. The facility's investigation initially failed to recognize the incident as abuse, despite the clear violation of the resident's privacy and dignity. Interviews with staff revealed that the CNA was known to frequently use her phone during work hours, and other staff members were present during the incident but did not intervene. The facility's outdated policy on personal cell phone use contributed to the failure to prevent the incident. The facility's policies on social media and abuse prevention were not effectively enforced, leading to the CNA's inappropriate actions and the subsequent failure to recognize and report the incident as abuse.
Removal Plan
- RN #502 and LPN #506 spoke with CNA #500 advising her of the allegation received that she posted something on Snapchat and that they need to see her phone. RN #502 reviewed the contents of the phone and observed the video of Resident #28. The nurses made CNA #500 delete the video from the camera roll and the recently deleted section of her phone.
- RN #502 informed CNA #500 she was suspended, and CNA #500 was escorted from the building.
- RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28's family was notified.
- The Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff to determine if they have witnessed or were aware of any staff taking pictures or videos of residents on their phones. There were approximately 22 as needed (PRN) staff who had not received education with education on-going as PRN staff arrived on-site for their scheduled shifts.
- The Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past. The CNA denied taking other pictures or posting videos of other residents. No other pictures or videos involving other residents were noted on the phone.
- The Administrator sent text messages to approximately 77 employees (all staff members for which the Administrator had cell phone numbers, out of 118 staff) in regards to social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule. PRN staff and staff who worked one to two days a month would be educated as they arrived to work.
- RN #511 provided re-education to 33 staff who arrived for their scheduled shift related to the facility social media policy, which included protecting the privacy of others, and personal cell phone use.
- The Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form.
- Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28.
- A meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time.
- CNA #500's employment was terminated.
- An AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 was held to notify Medical Director #512 of the State agency Immediate Jeopardy. A discussion was held regarding on-going education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care.
- Signs were posted in resident care areas which stated: no cell phone usage on the floor.
- Re-education on the facility abuse policy and the relation to the social media policy was completed with all staff in-person or via phone conversation by facility department heads.
- All residents with a Brief Interview for Mental Status (BIMS) score of eight or higher, Residents #8, #24, #36, #43, #54, #67, #71, #72, and #73, were interviewed by Bookkeeper #515 related to Privacy/Confidentiality.
- Corporate QA #514 re-educated the Administrator on the facility abuse policy and reasonable person concept. The reasonable person concept would be utilized for future investigations. The DON was also knowledgeable of the reasonable person concept and verbalized understanding if she was required to report an SRI. The facility implemented a plan for Corporate QA office staff to monitor abuse allegations on an on-going basis.
- Regional QA Nurse #503 completed an addendum for the facility SRI involving the incident with Resident #28. The addendum noted the allegation of abuse was substantiated.
- The facility implemented a plan to monitor/audit for cell phone use on the unit and ensure residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits.
- The DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education.
Penalty
Resources
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The facility failed to follow its abuse policy by not reporting multiple resident‑to‑resident physical altercations as abuse allegations to the State Agency. In several events, a cognitively impaired resident with documented aggressive behaviors pushed and struck other cognitively impaired residents in common areas and in a room, including hitting another resident in the abdomen and head and punching a resident in the face, while another incident involved a resident hitting a severely impaired resident in the chest, who reported that it hurt. Staff separated residents, assessed them, and documented no visible injuries, and internal incident reports were completed. However, leadership, including the Administrator, DON, and other clinical leaders, stated they did not submit self‑reported incidents because they believed there were no injuries and that the residents lacked the ability to intend harm or cause mental anguish, despite facility policies defining physical abuse as hitting or punching and requiring immediate reporting of alleged abuse and use of the reasonable person concept.
A resident with ADHD and other psychiatric and neurologic conditions was ordered Adderall 20 mg twice daily, but narcotic count sheets showed multiple instances where the count decreased by two pills when only one was ordered, all signed out by an LPN. The DON identified inaccurate counts tied to this LPN, who later stated she did not know why the count was wrong and claimed to have wasted a pill without a witness. The LPN refused an in-facility urine drug screen and did not appear for the initially scheduled independent test, yet was allowed to return to work despite a written Drug Free Safety Policy stating that refusal or failure to comply with required testing constitutes a refusal to test and results in termination.
The facility failed to implement its abuse policy after two residents in a secured memory care unit were involved in an incident of alleged sexual contact. A cognitively intact resident with a history of sexually inappropriate behavior was observed by therapy staff with his hand on the genital area of another resident with severe dementia, rubbing and squeezing through clothing. A CNA reported the incident to the ADON, and an NP assessed both residents and documented that staff described the behavior as an attempt to ejaculate the cognitively impaired resident, who did not understand what was happening. Despite a facility policy defining sexual abuse as any non-consensual sexual contact, including unwanted touching of the perineal area, the Administrator stated the event was not sexual abuse or reportable because both residents were clothed, and acknowledged that the abuse policy, required reporting to the state, and a thorough investigation were not carried out.
A resident with dementia and severe cognitive impairment was verbally abused by a CNA, an incident that was witnessed by staff and substantiated by the facility. Although the family was notified, there was no timely documentation that the physician, social services, or psychiatric services were informed, and no evidence of prompt psychosocial or psychiatric follow-up, despite facility policies requiring immediate protection, assessment, and notification after abuse allegations.
The facility did not properly identify or track a CNA as a suspected perpetrator in multiple abuse investigations, despite being aware of her involvement in incidents where she yelled at and acted aggressively toward two residents, including one with dementia. Staff reports and police involvement confirmed repeated concerns, but the facility failed to document the CNA in the required SRI tracking sections, contrary to policy.
A resident with cancer and dementia, who was alert and oriented, reported to several staff members that she was being verbally abused by night shift CNAs, including the use of profanity. These concerns were relayed to nursing staff and administration, and also reported to a hospital social worker, who notified the facility. Despite these reports, facility leadership stated they were unaware of the allegations, and no SRI was filed or investigation initiated as required by policy.
Failure to Report Resident‑to‑Resident Physical Altercations as Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by timely reporting multiple resident‑to‑resident physical altercations as allegations of abuse to the State Agency. In one series of incidents, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, obesity, and documented behavioral symptoms including verbal and physical aggression, wandering, rummaging, and taking others’ belongings was involved in a physical altercation with another resident who also had Alzheimer’s disease, dementia with agitation, depression, anxiety, and wandering and aggressive behaviors. Nursing notes and internal risk reports documented that one resident slammed a dining room chair into a table, the other resident pushed him in the abdomen, and the first resident then struck the other on the back of the head. Staff separated the residents, assessed them, and documented no injuries, and internal incident reports were completed. However, the Administrator and DON confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s policy and abuse flow sheet referencing the reasonable person concept and the need to report resident‑to‑resident physical altercations that could cause injury, pain, or mental anguish. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst and found the cognitively impaired, wandering resident sitting in his wheelchair eating dinner while the aggressive resident was on the bed. The resident in the wheelchair reported that the other resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were immediately separated, no injuries were observed, and notifications within the facility were made. The resident who reported being punched had Alzheimer’s disease with late onset, unspecified psychosis, vascular dementia, personality disorder, anxiety disorder, and wandering and aggressive behaviors documented on the MDS and care plan. Despite the allegation of being punched in the face and the facility’s written policy defining physical abuse to include hitting and punching and requiring immediate reporting of alleged violations involving abuse, the Administrator and DON again confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents involved could not intend to harm or cause mental anguish. Another incident involved a resident with dementia, delusions, severe cognitive impairment, and extensive behavioral symptoms such as exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, grabbing, kicking, hitting, pushing, cursing, anger, and agitation, who struck another severely cognitively impaired resident with multiple medical conditions including vascular dementia, COPD, heart disease, chronic kidney disease, malnutrition, and pain. An incident audit report and a physical aggression form documented that a CNA witnessed the aggressive resident hit the other resident in the left side of her chest with her hand in a common area, immediately redirected the aggressor, and notified the nurse. The nurse assessed the struck resident, documented no redness or bruising, obtained vital signs, and recorded that the resident stated it hurt but did not know why she had been hit. The physician and family were notified and monitoring was ordered. The DON stated that a self‑reported incident was not completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s abuse policy defining physical abuse to include hitting and requiring reporting of alleged violations involving abuse to the State Agency within specified timeframes. Across these events, the facility conducted internal investigations and documentation but did not treat the resident‑to‑resident physical altercations as reportable abuse allegations under its own policies and procedures.
Failure to Enforce Misappropriation and Drug-Free Workplace Policies for Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies related to misappropriation and drug-free workplace requirements in connection with a resident’s controlled medication. One resident, admitted with multiple diagnoses including ADHD, bipolar disorder, seizure disorder, and Tourette’s Disorder, had an order for Adderall 20 mg twice daily at 8:00 A.M. and 3:00 P.M. The resident’s MDS showed the resident was cognitively intact and independent with ADLs. Review of the resident’s Adderall narcotic count sheets showed that on specific dates, the pill count decreased by two tablets at times when only one tablet was ordered to be administered, indicating that two pills were signed out instead of one on multiple occasions. The facility’s SRI documented that the DON became aware that the Adderall count for this resident was inaccurate and identified that an LPN had signed out the medication at the times when the count decreased by two instead of one. During an interview, the LPN stated she did not know why the count was incorrect and claimed there was a day she punched out two capsules and wasted one but could not find another nurse to witness the waste. The DON reported that the LPN refused to complete an in-facility urine drug screen and did not appear for the initially scheduled independent drug test, despite facility policy stating that refusal or failure to comply with testing requirements constitutes a refusal to test and is subject to immediate termination. The DON acknowledged that, contrary to the written Drug Free Safety Policy, the LPN was allowed to return to work after refusing and missing the drug test, even though the policy specified that refusal to submit to required testing would result in termination.
Failure to Implement Abuse Policy After Allegation of Sexual Contact Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy when an allegation of sexual abuse occurred between two residents in the secured Memory Care Unit. One resident, who was cognitively intact with diagnoses including major depressive disorder, intellectual disability, morbid obesity, pulmonary embolism, and diabetes mellitus, was ordered to reside in a locked men’s unit for safety of self and others. This resident had a known history of sexually inappropriate behaviors with another resident who had since been discharged. The other resident involved had diagnoses including dementia, insomnia, major depressive disorder, hypertension, and diabetes mellitus, and was care planned for impaired cognition with short- and long-term memory impairment and severely impaired decision-making ability. On the date of the incident, staff including a CNA, an OTA, and a PT observed the cognitively intact resident seated next to the severely cognitively impaired resident in a common television room. The OTA and PT reported seeing the cognitively intact resident’s hand on the other resident’s genital area, squeezing and rubbing through clothing. The CNA reported that the therapists told her the same and that she then notified the ADON. Nursing documentation indicated that the cognitively intact resident was observed with hand contact to the other resident’s genital area while both were seated in the common area, and that staff intervened and redirected the resident away. The NP documented, as a late entry, that she was called about the incident, assessed both residents, and was told by staff that the cognitively intact resident was attempting to ejaculate the severely impaired resident by rubbing his penis up and down through clothing, and that the impaired resident did not appear to understand what was happening. Despite these observations and the facility’s written policy defining sexual abuse as non-consensual sexual contact of any type, including unwanted intimate touching of the perineal area, the Administrator did not treat the event as sexual abuse. The Administrator stated he did not consider the incident to be sexual abuse or reportable because both residents were fully clothed and asserted that nothing happened to the cognitively impaired resident. He acknowledged that the cognitively intact resident had a history of sexually inappropriate behavior and that the other resident was severely cognitively impaired and unable to consent to being touched in that manner. The Administrator further verified that the facility did not implement its abuse policy, did not report the allegation to the state agency, and did not complete a thorough investigation as required by the facility’s abuse, neglect, and misappropriation policy, which mandates prompt and thorough investigation and immediate reporting of any abuse allegations to the Administrator/designee and the Department of Health and social services, and requires that any situation where a resident may not have capacity to consent to sexual activity be treated as alleged sexual abuse. Additional documentation showed that after the incident, the cognitively intact resident was given an order for medroxyprogesterone for high-risk sexual behavior and was later care planned for sexually inappropriate behaviors with other residents, and an IDT note described another observation of this resident placing his hand on another resident’s perineal area. However, the medical records for both involved residents contained no documented evidence that either was evaluated by psychiatric services immediately following the initial incident. Interviews with the NP and staff confirmed that the NP was informed of the sexually inappropriate contact, assessed both residents, and communicated with the MD and DON, but the facility still did not activate its formal abuse investigation and reporting process as outlined in its policy. This sequence of events and omissions led to the cited deficiency for failure to implement the abuse policy in response to an allegation of sexual abuse.
Failure to Implement Abuse Policy and Timely Psychosocial/Medical Notifications After Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policies by not providing timely interventions and required notifications after an allegation of staff-to-resident verbal abuse. A resident with Alzheimer’s disease, dementia, anxiety, hypertension, dysphagia, and severe cognitive impairment, admitted in late August 2024, was the subject of a substantiated verbal abuse allegation involving a CNA who was observed speaking inappropriately to the resident. The incident was self-reported by the facility, and the resident’s family was notified of the allegation on the day it occurred. However, review of the medical record and facility documentation from the date of the incident through early February 2026 showed no evidence that the physician, social worker, or psychiatric services were notified in a timely manner, despite facility policy requiring such notifications and follow-up. Progress notes lacked documentation of any psychosocial assessment or psychiatric follow-up after the alleged abuse. Interviews with the DON, ADON, and LSW confirmed that social services and psychiatric services were not promptly informed and that psychiatric services were notified only several days later, contrary to facility policy that calls for immediate protection of the resident, examination for injury or psychosocial needs, and provision of emotional support and counseling as needed.
Failure to Identify and Track Suspected Perpetrators in Abuse Investigations
Penalty
Summary
The facility failed to ensure that Self-Reported Incident (SRI) investigations were complete, specifically by not identifying suspected perpetrators (SP) in the SRI tracking section, despite being aware of the staff member involved. In two separate incidents involving two residents, a Certified Nursing Assistant (CNA) was named in the investigations for yelling at and raising her arm toward residents, one of whom had dementia and only spoke Spanish. The CNA was reported by other staff for aggressive behavior, including yelling at residents and demanding they speak English. Despite these reports and the CNA being named in multiple SRIs, the facility did not list her as an SP in the required tracking sections, even after being notified by the State agency to do so. Further review revealed that the same CNA was involved in several other SRIs, yet the facility continued to omit her from the SP tracking section. The facility's policy required accurate and timely reporting of all incidents and identification of those involved, but this was not followed. Interviews with staff confirmed the CNA's behavior and the lack of appropriate action or documentation by the facility. The deficiency affected two residents directly and had the potential to affect all residents on the secure unit.
Failure to Investigate and Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for investigating and reporting an allegation of verbal abuse involving one resident. The resident, who had diagnoses including malignant neoplasm of endometrium, malignant neoplasm of cerebral meninges, and dementia, was alert and oriented, and had a care plan addressing behavioral issues such as refusal of care and accusatory behavior toward staff. The resident reported to multiple staff members, including CNAs and an LPN, that she was being treated rudely and subjected to profanity by night shift CNAs. These staff members stated they reported the allegations to nursing staff and administration. The resident also reported the abuse to a hospital social worker during a hospital stay, who then informed the facility and its hospital liaison of the allegations. Despite these multiple reports, facility administrative staff, including the Administrator, DON, and ADON, stated they were unaware of any abuse allegations regarding this resident. Review of facility records and the Ohio Department of Health reporting system confirmed that no Self-Reported Incident (SRI) was filed for this allegation, and no investigation was initiated as required by facility policy. The facility's policy mandates that all abuse allegations be reported to the Administrator, investigated, and reported to the State Survey Agency within five working days, which did not occur in this case.
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