F0610

D

Failure to Thoroughly Investigate and Document Abuse, Neglect, and Misappropriation Allegations

Laplata, Maryland Survey Completed on 01-09-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to conduct thorough investigations and maintain complete written records for abuse, neglect, and misappropriation allegations. For one resident with no cognitive impairment, chronic pain syndrome, and a documented preference for choosing between a shower or bed bath, the record did not show that staff determined or documented the resident’s bathing preference or frequency. When this resident later reported neglect concerns about pain medication not being given for 24 hours, not receiving daily showers as preferred, and experiencing trauma triggers related to stress and being in a nursing home, the facility’s investigation file lacked key elements. The initial report did not identify to whom the concerns were reported, and the final report did not include a resident statement, interviews with other residents about showers or trauma care, or staff statements. A census sheet used as part of the investigation had check marks and a note about residents having no concerns with pain medications but lacked dates, times, and the name or signature of the interviewer. There was no evidence that staff investigated why the resident was not receiving daily showers, why the resident’s pain was not controlled, or how trauma triggers had not been identified during trauma screening.

For another resident with a history of stroke and mild cognitive impairment, the facility failed to fully document and investigate an allegation of physical abuse by staff. The resident’s physician documented a need for PT and OT, and care plan meeting notes were entered by the unit manager and social services director on different times and as a late entry. The initial abuse report documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at a specific time, but did not state to whom it was reported. The final investigation report stated that a family member reported the allegation during a care plan meeting and that the resident said two staff members kicked the resident in the stomach on a prior evening. The abuse was deemed unsubstantiated because the alleged perpetrators were not identified and the resident could not clearly describe the incident, and it was noted there was only one male therapist in the facility. The SSD’s written statement did not include the date and time she was told of the allegation or when and to whom she reported it. Although statements were obtained from two male staff who cared for the resident that evening and from the male therapist, the facility did not obtain statements from other staff who worked that evening/night.

In a separate incident involving potential misappropriation of narcotics, the facility failed to complete a thorough investigation and maintain adequate documentation. The initial information provided to surveyors consisted only of the initial report to the state agency and the Board of Nursing regarding an RN who had been a unit manager. According to these documents, the RN removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a witness present. The DON stated that they were unable to determine whose medications were destroyed, although a call to the pharmacy with the prescription number could have clarified this. Review of narcotic logs showed that narcotics were sometimes documented as sent home with residents at discharge and sometimes as destroyed. The DON acknowledged that, during the investigation, they did not verify whether narcotics documented as sent home or destroyed on that unit during the RN’s tenure were accurate, and that their only verification was that all medications were signed off. No additional investigative information was provided to surveyors before exit.