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F0610
E

Failure to Protect Residents During Abuse Investigation

Mitchell, Nebraska Survey Completed on 06-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from further potential abuse during the investigation of an alleged abuse incident involving a nurse and a resident. According to the facility's abuse policy, there should be evidence that all investigative components are thoroughly investigated and that further abuse, neglect, exploitation, or mistreatment is prevented while the investigation is ongoing. However, the Director of Nursing (DON) confirmed that the alleged employee, an LPN, was not suspended or otherwise restricted from resident care during the investigation, as the DON believed nothing had happened. The LPN in question had access to all residents in the building while on shift, despite being formally assigned to half the building. The DON, who is a sibling of the LPN, stated that all disciplinary actions regarding the LPN were handled by the former Nursing Home Administrator (FNHA). The DON was made aware of the incident several days after it occurred and conducted interviews, but did not suspend the LPN during the process. The Nursing Home Administrator (NHA) later confirmed that there was no documentation of the initial investigation and only provided employee statements and an investigation summary after re-obtaining statements from staff. The facility's records showed that the LPN was not scheduled to work for several days following the incident, but this was due to the original schedule and not as a result of any suspension or protective measure.

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