F0607

D

Failure to Implement Abuse Reporting and Investigation Procedures After Resident Allegation

Salisbury, North Carolina Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse policy and procedures for reporting, investigating, and protecting a resident after an allegation of abuse. The facility’s written policy required that all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation, misappropriation of property, and injuries of unknown origin be immediately reported to the Administrator/Abuse Coordinator, that an investigation be initiated immediately, that applicable state and local agencies be notified, and that any accused staff member be removed from resident care and placed under supervision pending the outcome of the investigation. The policy also required notification of the resident’s responsible party and attending physician, documentation of assessments and notifications in the medical record, and involvement of social services when appropriate.

The resident involved was readmitted with hemiplegia, diabetes, and dementia and was assessed as moderately cognitively impaired, with clear but sometimes difficult speech, adequate vision and hearing, and a need for substantial assistance with toileting and bed mobility. On the morning after a night shift, multiple staff members, including the Activities Director, Activities Assistant, Environmental Supervisor, and nursing assistants, independently encountered the resident crying, upset, patting the left side of her face, and repeatedly saying “hit-hit” or similar phrases, sometimes naming a male staff member. Several staff observed the resident’s left cheek as pink, swollen, or puffy, and one NA reported seeing a bruise under the left eye. These staff documented handwritten statements and reported the allegation to the Administrator and Unit Manager. The resident’s representative also observed the resident upset with a pink cheek and reported that the resident indicated she had been hit.

Despite these reports, the medical record contained no nursing notes documenting an allegation of abuse, and the nurse assigned to the resident on the day of the allegation stated she was told by the DON not to worry about charting because the DON would take over the investigation. The Unit Manager and another nurse reported performing skin assessments, but documentation was delayed or absent, and the Unit Manager stated she was waiting for direction from the Administrator regarding documentation. The Administrator, after a brief interaction with the resident in which she physically demonstrated how an arm might rest against the resident’s jaw during incontinence care and asked if that was what happened, concluded the allegation was not valid due to the resident’s cognitive status, did not treat it as an abuse allegation, did not suspend the alleged perpetrator, and did not complete or submit an initial 24‑hour abuse report to state agencies. The alleged staff member continued to work multiple 12‑hour shifts, was never interviewed or asked for a written statement about the incident, and social services, the NP, ADON, and DON were not promptly or formally engaged in a documented investigation. Several leaders, including the DON and ADON, later reported that they had been told by the Administrator that the incident was already determined to be related to incontinence care and that the investigation was complete, and the HR Director reported that staff were upset that an investigation had not been completed in the manner they expected. These actions and omissions demonstrate the facility’s failure to follow its own abuse policy regarding immediate reporting, thorough investigation, documentation, and protection of the resident after an allegation of abuse.