F0610

J

Failure to Conduct Thorough Abuse Investigations

Atlanta, Georgia Survey Completed on 03-01-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of abuse, including physical and sexual abuse, involving numerous residents. For several incidents, the facility notified local law enforcement and obtained case numbers but did not follow up with the police department to obtain information about their investigations. In the cases involving a resident with a history of stroke who alleged being punched by another resident, later alleged sexual touching by a male resident, and was involved in a separate altercation with another resident who threw items at her, the facility’s investigative files lacked follow-up with police, interviews with other residents who may have witnessed or had knowledge of the events, and timely physical and psychosocial assessments of the involved residents. Similar investigative gaps were identified in an incident where a resident with an above-knee amputation was alleged to have hit another resident.

The facility also failed to complete thorough investigations into serious allegations of sexual abuse between residents with significant psychiatric and cognitive diagnoses. In one incident, a CNA reported finding one resident bent over another resident’s bed with his penis in the other resident’s mouth; both residents had diagnoses including paranoid schizophrenia and vascular dementia. Although police were notified and a case number was obtained, the facility did not follow up with law enforcement, did not interview other residents who may have been exposed to or had knowledge of the incident, and did not complete timely physical or psychosocial assessments of either resident. In another case, a cognitively impaired resident reported being touched on the thigh by another resident with severe cognitive impairment while in bed; both residents later denied or could not recall the event, and the facility did not obtain statements from other potentially affected residents or staff who may have been present, determining the allegation unsubstantiated based solely on the residents’ lack of recall.

Additional deficiencies in abuse investigations were identified in incidents of resident-to-resident physical abuse and alleged staff-to-resident abuse. In one case, a cognitively intact resident reported that another resident with dementia pinched her breast; while the facility determined that abuse occurred and documented some interviews, it did not obtain statements from other residents potentially affected or staff who may have been present. In another incident, a resident with Alzheimer’s disease and severe cognitive impairment sustained a head laceration when a nurse aide allegedly grabbed the resident by the sweater and shirt, jerked the resident from a seated position, and swung the resident toward the bathroom, causing the resident’s head to hit the doorframe; despite witness statements from another aide and an LPN, the facility ultimately determined it could not verify abuse after the resident later denied being abused. In a separate complaint from a resident with severe cognitive impairment and significant behavioral disturbances, who alleged that an LPN tried to force a pill down his throat and hit him with a TV remote, the facility’s investigation included multiple documents and interviews but did not include interviews of other residents cared for by the implicated LPN.

The pattern of incomplete investigations extended to additional resident-to-resident physical abuse incidents. In one event, a resident with vascular dementia and a history of breast cancer attempted to hit a nurse and then slapped another resident with dementia and diabetes in the face; the facility notified responsible parties and updated care plans but did not document interviews with other residents in the area or psychosocial assessments of the involved residents, despite notifying police and receiving a case number. Across these events, the Manager of Quality/Risk Manager, who conducted most of the abuse investigations, confirmed that investigation information was never obtained from the local police department, that timely physical and psychosocial assessments were not completed, and that residents who may have been present or had knowledge of the incidents were not interviewed. The Administrator, who served as the Abuse Coordinator and reviewed investigations, acknowledged that the referenced investigations were not complete, even though facility policy required identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.