Failure to Implement Abuse and Drug Prevention Policies Resulting in Resident Overdose
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of one resident who was found unresponsive and later tested positive for Methadone, a medication for which he did not have a physician's order. The resident, who had a history of drug and alcohol abuse, was admitted with multiple medical conditions including acute systolic heart failure, stroke, and major depressive disorder. On the day of the incident, the resident was found in respiratory distress and was only responsive to sternal rub, with an oxygen saturation of 47% on room air. He was transported to the hospital, where he was diagnosed with hypoxia likely due to acute-on-chronic systolic heart failure, and laboratory results revealed the presence of Methadone and opiates in his system. Upon interview, the resident stated that he had received Methadone from a staff member, although he refused to identify the individual and later denied the incident during subsequent interviews. Facility records showed that the resident had not signed out to leave the facility, and there was no physician order for Methadone in his medication records. Staff interviews indicated that they were unaware of the resident having access to nonprescription drugs or staff providing such substances. The facility's policies required prompt investigation and reporting of abuse, neglect, and drug-related incidents, but there was a delay in initiating a provider investigation and submitting a self-report to the state agency. The facility's leadership, including the DON and Administrator, did not immediately act upon learning of the Methadone finding in the resident's hospital records. The investigation and required notifications were not initiated until after the state investigator became involved. There was no evidence provided of medication audits, safe surveys, or timely reporting to the state agency prior to the identification of Immediate Jeopardy. This lapse in following established policies and procedures resulted in a deficiency related to the facility's failure to protect residents from abuse and to ensure a safe, drug-free environment.
Removal Plan
- Alleged employee suspended pending investigation
- Attending Physicians was notified of the incident involving the resident
- Trauma screen was completed
- Police notified
- Resident referred to Deer OAKS for psychological assessment
- Care plans updated
- Reviewed out on pass
- Reviewed advance entry for visitors
- Reviewed facility medications for use of methadone
- Completed care plan conference with residents
- Resident seen by psychologist
- Drug abuse contract and policy discussed with residents and signed
- Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration, and will be completed. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift
- Abuse and neglect in-service started and will be completed. All staff in services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC
- Staff and resident questionnaires
- Safe surveys
- Offered drug rehab services to resident
- Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee
- Appropriate interventions are being put in place as needed
- All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted and ongoing
- The Administrator/DON will review the effectiveness of this daily and weekly, then monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery
- The Medical Director met with the Interdisciplinary team and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy, the Plan of removal was reviewed and accepted by Medical Director
- An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal
- The Director of Nursing and Administrator will be responsible for the implementation of Process
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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