F0607

E

Failure to Report and Investigate Abuse Allegations per Policy

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse reporting and investigation policy for two residents who made abuse-related allegations. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, documentation showed that the resident was alert, oriented, and able to verbalize events. After admission following a ground-level fall at home, the resident experienced a fall in the facility and later expressed dissatisfaction with the facility without initially providing details. A late entry incident note documented that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, prompting notification of the ED, DON, physician, and family.

The initial facility report to the State Agency stated that this resident told an unnamed therapist that he did not want care from a CNA assigned to him and alleged that this CNA had caused multiple broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, and facility documentation indicated that there was a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The report noted that the CNA was immediately suspended and that the facility was contacting other agencies. However, there was no evidence in the clinical record or facility documentation that this allegation was reported to law enforcement or APS, that a thorough investigation was conducted, or that the results of the investigation were submitted to the State Agency within five working days.

For a second resident with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, care plans and notes indicated the resident was encouraged to participate in ADLs and was documented as alert and oriented. Psychology notes referenced an “incident last week” and stated there was no evidence of psychological harm and no further conflicts, but did not describe the incident. An initial facility report to the State Agency later documented that this resident reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, there was no evidence that this allegation was reported to law enforcement, that a thorough investigation was completed, or that the results of the investigation were submitted to the State Agency within five working days.

Interviews with the DON, administrator, RNs, and the social services director confirmed that investigations related to these two residents were not available and that the facility followed a record retention policy under which incident reports and self-reports were only kept for 12 months and grievances for three years. The DON and administrator stated they could not locate any evidence of the investigations for these incidents, and the DON referenced that the requested investigations were “outside the guidelines” for document retention. Staff interviews described the facility’s general procedures for responding to abuse allegations, including ensuring resident safety, separating alleged perpetrators, suspending staff when implicated, and reporting to the ED, DON, Ombudsman, police, physician, family, and State Agency. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program required identification, investigation, and reporting of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property within required federal timeframes and protection of residents from further harm during investigations, but the documentation for these two residents did not demonstrate that these policy requirements were carried out.