F0610

D

Failure to Immediately Report and Investigate Abuse Allegations and Protect Residents

Hermitage, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that all allegations of abuse were immediately reported, investigated, and that protective measures were implemented during the investigation for all residents, including two identified residents. Facility policy stated that residents would be free from abuse, that all employees alleged to have committed abuse would be suspended immediately pending investigation, and that accused residents would be isolated and monitored. The policy also required immediate or 24‑hour reporting to the State Survey Agency and law enforcement, and completion of investigations within five working days. Despite this, staff did not promptly report or act on allegations of abuse involving two residents, and the alleged staff perpetrator continued to work with residents after an incident was witnessed.

For the first resident, who had vascular dementia with agitation, severe cognitive impairment, and resided on a special care unit, the Administrator learned of possible abuse only after the resident’s responsible party reported bruises on the resident’s hands and arms and relayed that an unnamed staff member had said a CNA abused the resident. A progress note documented scattered bruising on both upper extremities in various stages of healing, with the resident stating he or she woke up that way and denying pain or functional impairment. The Administrator’s subsequent review of video footage from the special care unit hallway showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions. Interviewed staff reported that on the morning of the incident, one CNA heard the alleged perpetrator repeatedly yelling at the resident to get back in bed, observed the CNA holding the resident’s forearms while the resident struggled to get free, and saw the CNA continue to push the resident toward the bed while holding the resident’s arms. That CNA stated he or she told the CNA to leave the room and the unit, and later called the nurse to look at the resident’s arms, expecting an incident report to be made.

However, the LPN on duty that morning stated that no one informed him or her of any incident involving the resident and the CNA, and also reported not going to the special care unit to make rounds due to lack of time. Another CNA stated that he or she was told about the abuse by the witnessing CNA but did not report it, believing it had already been reported to the Administrator. The DON and other nursing staff indicated in interviews that grabbing a resident’s arms and causing bruising would be considered physical abuse and that alleged perpetrators should be removed from resident care areas and suspended pending investigation, but the Administrator confirmed that the CNA worked additional overnight shifts on the special care unit after the alleged abuse and before the allegation was brought to his or her attention. This sequence of events shows that the allegation was not immediately reported through the chain of command, the resident’s immediate safety was not ensured, and the alleged perpetrator was not promptly removed from resident care.

For the second resident, who had dementia, depression, anxiety disorder, delusional disorder, paranoid personality disorder, severe cognitive impairment, and dependence on staff for multiple ADLs, there was also a failure to recognize and report an allegation of abuse. The resident’s care plan noted mood distress, crying, and cognitive deficits, and a progress note documented episodes of increased confusion and hallucinations, including the resident asking for specific individuals and misidentifying men in the facility as others. The hospice RN who visited weekly reported that during the prior two weeks the resident had said, “Don’t let that man in here. He’s raped me.” The hospice nurse stated that he or she “blew it off,” believed he or she may have mentioned the comments to an LPN or the DON, did not document the allegation in notes, and did not know it had to be reported because the resident had dementia. The DON stated that the hospice nurse and any staff with knowledge of the resident’s comments should have immediately notified the charge nurse and the DON, and that the resident’s statement was considered an allegation of abuse. This demonstrates that the facility did not ensure that all staff, including contracted hospice staff, recognized and immediately reported allegations of abuse, resulting in a failure to initiate an immediate investigation and protective measures for this resident as required by facility policy and regulation.