Failure to follow abuse policy after a resident-on-resident assault. A resident with dementia and physically aggressive behaviors scratched another resident’s face, causing superficial marks to the chin and cheek. The injured resident had significant cognitive impairment and later reported that the other resident ran fingernails across her face. Staff confirmed the incident was abuse, but the clinical record contained inconsistent documentation and the behavior note did not include details of the assault.
Failure to report and investigate alleged sexual abuse: Staff heard rumors that a former CNA had sent or sold inappropriate photos to a resident with intact cognition, but the DON and administrator did not report the allegation because the resident denied having the photos. Interviews showed staff knew such conduct would be sexual abuse and that abuse allegations were to be reported immediately, while facility policy required all allegations to be reported and thoroughly investigated.
Failure to Report and Investigate Abuse Allegations: The DON, ADON, and Administrator did not treat a resident’s reported fight with a CNA and a separate resident-to-resident assault as reportable abuse events. Records showed conflicting resident statements, visible injuries, and staff accounts describing physical aggression, yet the incidents were not promptly reported to State agencies under the facility’s abuse policy. The Administrator stated the events were not considered abuse because of the residents’ statements and lack of willful intent.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
Failure to Report and Investigate Resident-to-Resident Abuse: The facility did not follow its abuse policy after an incident between two roommates, one with intact cognition and one with dementia and confusion. A nurse observed the male resident grabbing the female resident’s wrist while she tried to pull away, and the female resident stated he hit and grabbed her. Staff and leadership later confirmed that this was an allegation of abuse that should have been reported and investigated, but the facility did not report or investigate the incident as required.
Failure to Report and Document Alleged Neglect: A Nursing Student reported that a CNA did not provide cares to residents, including residents being left soaking wet and unchanged. The concern was relayed to facility leadership, but the allegation was not reported to the SA within the required timeframe and the investigation was not documented, despite the facility’s abuse/neglect policy requiring prompt reporting and a written investigation record.
Failure to Thoroughly Investigate and Report Alleged Resident-to-Resident Abuse: An alleged resident-to-resident abuse incident involved a resident with severe dementia and behavioral symptoms and another resident with severe cognitive impairment and a history of fearfulness and striking out. An LPN observed the incident, reported it to the DON and police, and an ADON reviewed video and concluded there was no contact, but no full abuse investigation was completed and no state agency report was made. Facility staff stated they believed a full investigation and reporting were unnecessary once no contact was confirmed, despite the abuse policy requiring thorough investigation and reporting of alleged violations.
A cognitively intact resident with multiple medical conditions had an abuse allegation reported by an outside complainant, who informed the Social Services Director that someone was allegedly trying to suffocate the resident with a pillow and that the resident was being forced to drink an unknown green substance. Although facility policy and staff statements indicated that any abuse allegation must be reported to the SA, APS, Ombudsman, and the Administrator within required time frames and investigated through interviews and documentation review, the Social Services Director did not notify any agencies or the Administrator and did not initiate an investigation, relying instead on the absence of abuse documentation in the medical record. The DON, an LPN, and the Administrator all reported that they were unaware of any allegation or investigation for this resident, and review of the written policy confirmed that the facility failed to follow its own procedures for reporting and investigating the abuse allegation.
A minor with TBI, ADHD, anxiety, and depression, whose healthcare decisions were made by a legal guardian and who required supervision with all decision-making, developed a close relationship with an adult resident with serious mental illness. Staff had prior concerns and had warned the adult that the other resident was a minor, and the guardian had been notified that the minor was to remain in public areas. One evening, an LPN entered another resident’s room and observed the adult on her knees in front of the minor, whose pants were down, in the bathroom; the residents were separated and the DON was notified. Both residents later acknowledged a sexual encounter, describing it as consensual and initiated by the minor, and the police classified the event as sexual assault of a minor and completed statutory rape. The facility’s 5-day investigation did not identify the younger resident as a minor in reports to the State Agency, concluded the event was between consenting individuals, omitted a statement from the nurse who discovered the incident, did not interview the room’s assigned resident or other residents about what they saw or heard, did not document protective interventions on the date of the incident, and did not report to child protective authorities at the time, despite policy requirements for prompt recognition, reporting, and thorough investigation of abuse.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
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