Incomplete investigation after an LPN left the unit multiple times during a shift and was later found lethargic with suspected drug paraphernalia. Twenty-two residents had omitted meds and/or tx, but the facility interviewed only six of the 29 residents on the unit instead of obtaining statements from all residents about whether they received their meds, had symptoms from missed doses, or observed unusual behavior from the LPN.
Incomplete Investigation of Resident-to-Resident Altercation: Two residents were involved in a physical altercation after one resident allegedly swung a cane at the other, leading to a push and punches. The facility separated the residents and initiated an investigation, but the record shows no detailed contemporaneous interviews from the involved residents and the investigation relied on conflicting witness accounts. Leadership later acknowledged they were not aware of the cane-related statement during the investigation, despite the abuse policy requiring allegations to be immediately and thoroughly investigated.
Failure to Investigate Injury of Unknown Origin: A resident with dementia, severe cognitive impairment, and total dependence for ADLs was transferred to the hospital during an overall decline with poor intake and medication refusal. Hospital imaging later identified vertebral compression deformities and fractures of the hip and femur, and the DON and ADON stated they were unaware of the hip fracture diagnosis and had not investigated the injury of unknown origin.
Failure to Thoroughly Investigate Allegation of Sexual Abuse: A resident alleged another resident touched him/her in the private area over clothing and blankets. The accused resident self-propelled throughout the building in a wheelchair, and staff reported seeing the resident in the other resident’s doorway. Although police and the provider were notified and the accused resident was sent to the ED for psych clearance, the facility did not interview other residents on the Annex unit who could have been affected, despite multiple residents living there with varying BIMS scores.
Incomplete Abuse Investigation: A resident with Alzheimer's disease and insomnia had an alarmed seat belt tied closed by an NA while the resident was in a wheelchair. The NA stated she did it to keep the resident from getting up and knew it would be considered a restraint, but the facility's abuse investigation did not include interviews with all staff working the shift, including another NA, an LPN, and the RN supervisor, despite policy requiring interviews of all involved persons and witnesses.
Failure to Investigate Allegations of Neglect: A resident on O2 had a family-reported incident involving an empty O2 tank, delayed staff response, and rough handling of tubing, while another report described an NA ignoring call bells, skipping rounds, and leaving residents dirty and incontinent overnight. Additional residents reported delayed toileting, poor linen care, and missed safety checks, and licensed staff said NAs were turning off call bells and refusing care tasks. The DON stated the concerns were not fully investigated or reported as required.
Failure to complete a thorough investigation of an abuse allegation involving a resident with severe cognitive impairment. Facility emails and staff interviews documented concerns that a family co-conservator had threatened to harm the resident with insulin, and police later trespassed the family member from the property. However, the DON stated no incident report or documented investigation was completed, no staff interviews or signed statements were obtained, and the event was not found on the state reporting website.
Failure to thoroughly investigate bruising of unknown origin. A resident with severe dementia and total dependence for many ADLs developed bilateral forearm bruising, and staff initially noted no pain, no known cause, and no witnesses. Later documentation described the bruises as dark red to maroon, and the DNS and ADNS acknowledged that staff statements were not obtained when the bruises were first found and that the incident was not fully investigated at that time.
A resident with Alzheimer's Disease, severe cognitive impairment, and known wandering and exit-seeking behaviors eloped through a rear exit door. RN and RA staff found the resident outside and escorted the resident back in without injury, but the DON did not interview all potential staff witnesses from the affected shifts to determine how the resident exited or whether the rear door had been left open, and the investigation was not thorough.
Incomplete investigation of scalp pressure injuries: A dependent resident with severe cognitive impairment and multiple chronic conditions was found to have a cluster of pressure injuries on the back of the head after the RP raised concern about scalp skin changes related to severely matted hair. Although the event was treated as possible neglect, the facility did not obtain statements from several RN, LPN, and NA staff who had worked with the resident or on the unit during the prior 72 hours, and the DON confirmed the investigation was incomplete.
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