Incomplete Investigation of Alleged Staff-to-Resident Abuse: A resident with moderate cognitive impairment and multiple medical conditions was involved in an alleged abuse incident during a transfer when staff observed her rigid and slipping from her wheelchair. Accounts differed, but witness statements and the resident’s report described an LPN hitting or smacking the resident’s legs while telling her to relax, and bruising was documented on the knees. The facility’s investigation was not thorough because it left out relevant written witness statements and still concluded the allegation was unsubstantiated.
Failure to Thoroughly Investigate Alleged Abuse: Staff found two residents involved in a hair-pulling incident after one resident was heard screaming and the other was found outside a room. One resident had dementia, wandering, and impaired decision making; the other had dementia, schizophrenia, hallucinations, and a history of aggression and wandering. Although the incident was reported and statements were taken, survey review found no evidence that the abuse allegation was thoroughly investigated or that the completed investigation was submitted to the State Agency within the required timeframe.
Failure to investigate a resident-to-resident abuse allegation. Two cognitively impaired spouses shared a room, and staff documented an altercation in which an LPN saw the male resident hit the female resident and later a nurse observed him grabbing her wrist while she reported that he hit and grabbed her. The DON and administrator stated the event was reportable and should have been investigated, but the facility did not complete an investigation for the second incident or report it as required by policy.
Failure to investigate and document an allegation of neglect: an RN received a Nursing Student’s report that a CNA was not providing cares and residents were left soaking wet and unchanged, and the complaint/grievance form was texted to the former ADM, DON, and SSD. The facility did not make its initial report to the SA until weeks later, the original grievance form could not be located, and no written investigation record was produced even though policy required prompt interviews of residents and staff and a written record.
Failure to fully investigate an abuse allegation involving two residents. One resident with severe cognitive impairment and another resident with severe dementia and psychotic disturbance were involved in an incident where an LPN documented that the second resident swatted and appeared to punch the first resident, and the second resident nodded yes when asked if he meant to hurt her. The ADON reviewed video and concluded there was no contact, told police no contact was made, and ended the inquiry without staff or resident interviews or contacting other agencies, despite the DON stating that resident-to-resident hitting is abuse.
The facility failed to complete a thorough investigation after a resident with multiple comorbidities and intact cognition was found with neck injuries that were later revealed to be self-inflicted in a suicide attempt using a razor. Although the resident expressed ongoing suicidal ideation and items such as a razor, letter opener, and pocket knife were removed from the room, the required five-day investigation report was incomplete, lacking resident and staff interviews, skin assessment documentation, a detailed description of events, and investigative conclusions, contrary to the facility’s abuse/neglect policy and the expectations described by the ADON and Administrator.
A cognitively intact resident with multiple medical conditions was the subject of an abuse allegation reported by a complainant, who stated someone was trying to smother the resident with a pillow and that the resident was being forced to drink an unknown green substance. The Social Services Director, who along with the DON is designated to receive and investigate abuse complaints, acknowledged receiving the complainant’s call but did not initiate an investigation because there was no documentation of abuse in the medical record and instead assured the complainant that no abuse had occurred. The DON, Administrator, and an LPN all reported they were unaware of any abuse allegation or investigation for this resident. Review of the State Agency database confirmed there was no facility self-report or 5-day investigation report, despite facility policy requiring prompt reporting and investigation of all suspected abuse incidents.
The facility failed to recognize and thoroughly investigate a sexual encounter between a minor and an adult resident as potential sexual abuse, instead documenting it as a consensual event between cognitively intact individuals. An LPN reported finding the two in a bathroom during the act and notified a supervisor, but the facility’s internal investigation omitted a written statement from this nurse, did not interview the roommate or other residents (including other minors), and relied on interviews with staff who had not worked the shift when the incident occurred. Clinical records showed only vague references to a “reported event” and did not document timely protective interventions on the date of the incident, nor any prior supervision or measures to limit the pair’s unsupervised contact despite staff awareness that one was a minor. The facility did not identify the younger resident as a minor in reports to the State Agency, did not report the incident to DCS, and did not follow its abuse policy requiring prompt, comprehensive investigation, resident protection, and mandated external reporting.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
The facility failed to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation involving several residents with complex medical and psychiatric conditions. In numerous cases of alleged resident-to-resident altercations, loss or misuse of funds, and inappropriate sexual contact, the facility could not produce five-day investigation reports, contemporaneous nursing notes, care plans, or even basic clinical records for the residents involved. Facility leadership acknowledged that records and investigation reports from before a change of ownership were unavailable, despite policy and record-retention expectations, resulting in an inability to verify that required abuse investigations were completed in accordance with the facility’s abuse prevention policy.
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