Failure to Timely Report and Document Multiple Allegations of Abuse and Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate multiple allegations of abuse and neglect involving several residents with dementia and related psychiatric diagnoses. One incident involved a CNA finding a resident with alcohol-induced dementia and Alzheimer’s disease standing by the head of another resident with Alzheimer’s disease and mood disturbance, with both residents’ pants lowered or partially down while the second resident was lying in the first resident’s bed. The CNA reported the situation to the nurse, who then notified the Nursing Home Administrator (NHA). The NHA acknowledged awareness of this incident but stated she did not report it to authorities because she arrived at the facility within 30 minutes and believed she could immediately rule out concerns. There were no incident reports, statements, assessments, or EMR documentation showing that the incident occurred or that any notifications were made to the physician or guardians. Another unreported incident involved a resident with alcohol-induced dementia and Alzheimer’s disease entering the room of a resident with Alzheimer’s disease and dementia, climbing into bed between the wall and the resident, and pushing his back against her, moving her toward the edge of the bed. The resident expressed concern about her baby doll being suffocated and about being pushed out of bed, and she got up to get the nurse. Staff statements documented that the resident reported being called a derogatory name before the other resident climbed into her bed. The NHA received calls from the facility during the night and was informed of the incident in the early morning hours. The NHA kept a “soft file” on the event, did not conduct an investigation at the time, and did not report the allegation to the State Agency. The NHA later stated she had been looking for willful intent, believed the resident was fine and not upset, and acknowledged that the verbal abuse should have been reported. Additional concerns involved a resident with dementia and behavioral disturbances who reportedly told her guardian and several family members that another resident grabbed her by the neck, held her head against the wall, and caused neck pain on Christmas Eve. An RN, after being questioned by the guardian about this event, could not find any incident report or documentation in the EMR and stated that the resident was in the hallway talking to staff with tears in her eyes and reported that an LPN had applied cream to her neck. The RN reported this to the NHA and was told the incident was already known and had been dealt with, while the NHA later denied awareness of any such incident. In a separate event, the same RN completed a Risk Management document for a scratch on a resident’s forearm after another resident walked past her, initially documenting it as a resident-to-resident incident. Management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost balance and accidentally scratched her. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These events occurred in the context of a written facility policy requiring immediate or timely reporting of all alleged violations of abuse, neglect, or exploitation to the Administrator, state agency, and other required agencies within specified timeframes, which was not followed in these cases.
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