Failure to Implement Enhanced Monitoring During Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement required protective measures during abuse investigations involving three residents. Facility policy dated December 2025 states that during an abuse investigation, the facility will take steps to prevent potential abuse, including assessing residents who allegedly abuse others to determine appropriate care approaches and placement, and taking all necessary steps to ensure safety, such as separating involved residents. On one occasion, an altercation occurred near the nurse’s station when one resident pushed another resident’s wheelchair, leading the second resident, who was alert and oriented, to grab the first resident’s nose, after which the first resident pushed the other’s hand/arm away. A CNA later asked the first resident to demonstrate what happened, and the resident grabbed and twisted the CNA’s nose, with an RN present. Interviews and record review showed no documentation that 15-minute checks or one-to-one supervision were implemented for either resident during the investigation of this allegation, despite staff acknowledging that such checks are sometimes used and are documented on paper forms uploaded into the EMR. In a separate incident, another resident was observed in the front lobby yelling that someone was trying to kill the resident’s son and made contact with a second resident in a wheelchair. Witness and resident interviews documented that the first resident bumped the second resident’s wheelchair, the second resident bumped back, and then the first resident grabbed the second resident’s wrist, though no injury was reported. Review of both residents’ medical records showed no documentation that 15-minute checks or one-to-one supervision were implemented during the investigation of this second abuse allegation. The administrator confirmed that for both incidents, 15-minute checks or one-to-one monitoring were not used and that staff instead checked on the residents every two hours and monitored their behaviors, contrary to the facility’s abuse prevention and reporting policy requirements for ensuring resident safety during abuse investigations.
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