F0610

E

Failure to Investigate and Document Multiple Abuse Allegations

Zeeland, Michigan Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to timely and thoroughly investigate multiple allegations of abuse involving several residents with dementia and related psychiatric diagnoses. One resident with alcohol-induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder was documented by a CNA as sexually inappropriate on a specific date. The CNA later described entering the resident's room and finding another resident with Alzheimer's disease and dementia with mood disturbances lying in his bed with her pants slightly down to her hips, while his pants were lowered with his buttocks exposed. The CNA reported this to a nurse, who then notified the Nursing Home Administrator (NHA). The Unit Manager/RN initially denied knowledge of any sexually inappropriate incidents or the documented behavior task, and there were no incident reports, statements, assessments, EMR documentation, or notifications to the physician or guardians regarding this event. The NHA acknowledged awareness of the incident and stated she did not report it because she arrived within 30 minutes and believed she could rule out concerns, later admitting there was no documentation of the incident or interventions.

Another incident involved the same male resident entering the room of a female resident with Alzheimer's disease and dementia in lack of coordination, climbing into bed with her, and refusing to leave. The female resident left the bed to seek help, reporting that the male resident called her derogatory names and climbed into her bed, pushing his back against her and moving her toward the edge of the bed while she worried about her baby doll and being pushed out. Staff statements documented that the male resident verbally abused her with profane language and had to be forcefully removed from the room. The NHA kept this incident in a "soft file," did not report it to the State Agency, and admitted she did not conduct an investigation at the time. A CNA reported being instructed by the nurse, per the NHA, not to document anything about the incident. Later, staff providing 1:1 supervision to the male resident did not know why he required such supervision, and there was no EMR documentation explaining the reason.

Additional allegations involved the same male resident and another female resident with dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. An RN reported that this resident's guardian called about a skin tear and relayed that the resident had told multiple family members that the male resident grabbed her by the neck, held her head against the wall, and hurt her neck on Christmas Eve. The RN could not find any incident reports or EMR documentation of this event, although the resident was observed in the hallway tearfully recounting the incident and stating that an LPN had applied cream to her neck. The RN stated she informed the NHA, who said the incident was already known and addressed, but the NHA later reported she was not aware of any incident between these two residents. In a separate event, an RN completed a Risk Management document when a resident with Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder was found with a scratch on her forearm after another resident with dementia walked past her. The RN initially documented it as a resident-to-resident incident, but management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost her balance and accidentally scratched her. The RN was told she could not document it as a resident-to-resident incident because she did not directly witness the scratch, and she did not complete a witness statement. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These actions and omissions occurred despite a facility policy requiring immediate investigation of suspected abuse, identification and interviewing of all involved persons, and complete and thorough documentation of investigations.

The facility’s abuse, neglect, and exploitation policy required immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, preserving evidence, investigating different types of alleged violations, interviewing alleged victims, alleged perpetrators, and witnesses, and providing complete and thorough documentation. Across the described incidents, the facility did not follow these procedures. There were repeated failures to initiate formal investigations, complete incident or risk management reports, document findings and interventions in the EMR, notify physicians and guardians, and accurately classify and record resident-to-resident altercations. In some cases, staff were explicitly instructed not to document incidents, and in others, documentation that initially identified resident-to-resident contact was later changed by management. The NHA acknowledged responsibility for the lack of documentation and agreed that at least one verbal abuse incident should have been reported, but contemporaneous investigative steps and required reporting were not carried out as outlined in the facility’s own policy.