F0610

E

Failure to Thoroughly Investigate Multiple Abuse Allegations and Ensure Required Notifications

Sandusky, Ohio Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of staff-to-resident abuse, primarily related to one CNA, and to ensure required notifications and documentation occurred. For one resident with Alzheimer’s disease, dementia, anxiety, hypertension, and dysphagia, staff reported an allegation of verbal abuse by a CNA during a lunch meal. The CNA was observed by another CNA and dietary staff cursing and yelling at the resident to wake up and eat while the resident was sleeping in the dining room. Although the facility substantiated verbal abuse for this resident, the investigation did not include interviews with all staff present in the dining room, including the registered dietitian who was on the unit at the time. Nurse’s notes for this resident showed family notification of the verbal abuse allegation, but there was no documentation of physician notification, no follow-up with social services, and no documented contact with psychiatric services despite an intervention for a psychiatric consult being implemented.

Additional allegations of abuse involving the same CNA and several other residents were reported by staff but were not fully investigated or documented. Multiple witness statements described the CNA force feeding residents and using sternal rubs to wake residents during meals. One CNA reported that the CNA had force fed two residents by forcing a spoon into their mouths when they resisted and had awakened two other residents during meals with sternal rubs; these incidents were reportedly told to two LPNs. Another CNA reported witnessing the CNA yelling at a resident and force feeding another resident, and stated he reported this to an LPN who then reported it to the ADON. Dietary staff reported that the CNA had cursed at residents and told residents to sit down and shut up or get their heads off the table, and that these concerns had been reported to a nursing supervisor. Despite these reports, there was no documentation that these additional allegations were investigated, no Self-Reported Incidents were submitted for the other residents named, and the involved CNA was not questioned about the additional abuse allegations.

Review of medical records for several residents identified in staff statements showed no documentation of abuse allegations, no related nursing notes, and no SRIs for staff-to-resident abuse for those residents. Interviews with nursing staff and supervisors revealed inconsistent awareness and follow-through on the reported concerns. One nursing supervisor acknowledged being aware of force-feeding allegations but did not report them because the CNA was already on administrative leave. The DON stated she had not reviewed the witness statements, had not been notified of force-feeding allegations, and confirmed that additional allegations discovered during the investigation were not reported or investigated and that required notifications and assessments were not completed. The facility’s own policies required immediate reporting of all alleged abuse, identification and interviewing of all involved persons and witnesses, notification of the Administrator, physician, family/legal representative, and police department as applicable, and thorough documentation of investigations and resident monitoring, but these steps were not carried out for the multiple allegations that arose during and around the initial verbal abuse incident.

Video surveillance of the lunch meal where the initial verbal abuse allegation occurred showed the presence of multiple staff, including the CNA accused of abuse, other CNAs, an LPN, the speech therapist, the registered dietitian, and dietary staff, but the dietitian was never interviewed. Staff interviews further showed that some nurses denied receiving reports of abuse that CNAs stated they had made, and that social services and psychiatric services were not promptly notified of the verbal abuse allegation involving the cognitively impaired resident. The licensed social worker reported she was not informed of the allegation until much later, despite the expectation that she be notified of abuse allegations. The ADON acknowledged awareness of a force-feeding allegation involving a former resident but confirmed it was neither reported nor further investigated. Collectively, these actions and omissions demonstrate that the facility did not follow its abuse reporting and investigation policies, did not fully investigate all reported allegations, and did not ensure appropriate documentation and notifications for the residents involved.

The facility’s written policies on Reporting Allegation of Abuse/Neglect/Exploitation and Abuse, Neglect, Exploitation required that all alleged violations of abuse be reported immediately, that all involved persons and witnesses be identified and interviewed, that the alleged victim be examined and monitored, and that complete and thorough documentation be maintained. The policies also required notification of the Administrator, facility police department, physician, and resident’s family or legal representative, as well as psychosocial assessment and emotional support as needed. In this case, the facility did not adhere to these requirements for the multiple allegations that surfaced, including those related to verbal abuse, force feeding, and inappropriate use of sternal rubs, resulting in an incomplete and insufficient investigation of alleged staff-to-resident abuse affecting multiple residents on the unit.