F0610

J

Failure to Investigate Injury of Unknown Origin and Allegations of Staff Abuse

Fort Collins, Colorado Survey Completed on 06-26-2025

Penalty

Fine: $32,810

Summary

The facility failed to initiate a thorough investigation of an injury of unknown origin involving a resident who was cognitively intact and required total assistance for transfers and mobility due to multiple medical conditions, including autoimmune disease, arthritis, edema, and a history of stroke. The resident reported sustaining an injury when a male CNA transferred her without a mechanical lift, resulting in pain, swelling, and ultimately a diagnosis of right distal tibia and fibula fractures. Despite the resident's ongoing complaints of pain and visible swelling, documentation in skin assessments and progress notes did not reflect these observations, and staff failed to conduct or document a timely and thorough assessment of the injury.

Staff interviews revealed that CNAs noticed the resident's complaints of pain and visible bruising but did not consistently report these findings to nursing staff, and there was no designated place in CNA charting to document new injuries. When a nurse was informed of the injury, he observed swelling and bruising but did not perform a full assessment, notify the physician or family, or document the findings, assuming that all parties were already aware due to pending Xrays. Other nursing staff stated that any change in a resident's condition, such as a swollen ankle, should prompt a full assessment, documentation, and notification of the physician and family, as well as reporting to facility leadership to rule out potential abuse, but these steps were not followed in this case.

Additionally, the facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident verbal and mental abuse reported by another resident. The resident reported feeling mentally and verbally abused by nursing staff, including being accused of medication-seeking behavior and being yelled at by a CNA. Despite reporting these concerns to the social services director and other leadership, there was no formal follow-up, and the staff members involved continued to work with the resident. The facility's investigation did not include interviews with other residents or staff, observations of interactions, or documentation of unofficial investigations, resulting in an incomplete response to the allegations.

Removal Plan

• Interview the resident by a clinical resource and the corporate licensed clinical social worker; provide psychosocial support and offer additional mental health support.
• Suspend the NHA and RN; suspend the CNA.
• Conduct education with the NHA, the SSD, and the DON on how to identify instances and allegations of abuse and the difference between a concern and forms of abuse; complete competencies.
• Provide education to the RN and CNA regarding the differences between concerns and forms of abuse and how to report appropriately; ensure the CNA does not return to work until education and return demonstration is provided in person.
• Initiate interviews with all residents who can participate to ensure all allegations of abuse are identified and thoroughly investigated; for residents who cannot be interviewed, reach out to the emergency contact/resident representative to discuss concerns; if an interview cannot be completed, have social services complete an observation to identify signs of psychosocial distress or change in mood; complete all interviews/observations.
• Educate all staff on identification of allegations of abuse versus customer service and abuse reporting, including differentiating potential abuse allegations from concerns/customer service issues; ensure any employee unable to complete education in person is educated prior to their next scheduled shift.
• Have social services or designee complete weekly audits on random residents, including resident interviews about abuse/observations of abuse and record review; if allegations are identified, notify the abuse coordinator per regulations, complete a thorough investigation with interventions to prevent recurrence, complete state occurrence reporting and police reporting; for concerns, complete corrective action; record audits on an audit form; promptly report discrepancies to the administrator; report results to the quality assurance committee.
• Have the director of nursing services or designee interview employees weekly for comprehension about types of abuse and signs of mental abuse, the difference between customer service concerns and allegations, and immediate reporting.
• Provide weekly oversight to review investigations and audit whether managers understand the difference between customer service concerns and allegations.