Failure to report an allegation of sexual abuse involving a second resident. Staff and resident interviews, along with record review, showed that an FRI addressed an incident involving one resident, but the DON’s email and resident statements identified another resident as also being involved in sexual activity with a male visitor. The facility did not include that resident in the FRI, despite a policy requiring all abuse allegations to be reported immediately to the Administrator and appropriate agencies.
Failure to timely report a resident-to-resident abuse allegation. A resident with moderate cognitive impairment reported that another resident with dementia made an inappropriate sexual comment in the lobby area, and the resident said no physical sexual act occurred. The resident told staff the same evening, but police were not contacted until the next day after the resident reported it herself, and the SA report was submitted later that day. The facility policy required immediate reporting, but not later than 2 hours, for abuse allegations.
Failure to Report Resident-to-Resident Altercation to SSA: The facility did not report a resident-to-resident physical altercation to the SSA within the required timeframe. A resident with diagnoses including schizoaffective disorder, dementia, psychosis, and major depression was in a shared bathroom when another resident with diagnoses including paranoid schizophrenia and Alzheimer’s disease entered, became aggressive, and pushed the resident, causing a fall. Staff documented the event as an altercation, and the Administrator later stated it was not reported because he believed there was no assault and thought it was unwitnessed.
Failure to Timely Report Allegations of Abuse: A resident with Alzheimer’s disease and behavioral symptoms was documented threatening, grabbing, pushing, and attempting to be physical with other residents on multiple occasions, but the incidents were not timely reported to the DON, SA, or local Ombudsman. In another event, two severely cognitively impaired residents were documented as engaging in a mutual sexual encounter, yet the facility had no incident report or SA report and had not assessed consent capacity. Interviews confirmed leadership was unaware of several incidents and acknowledged the reporting failures.
A resident reported an unauthorized online clothing purchase charged to their funds, and the facility documented this as an allegation of exploitation/misappropriation of property. Facility policy required prompt reporting of such allegations to the Abuse Coordinator, state agency, and law enforcement. However, there was no evidence that the Sheriff’s Department was notified, and later contact with an investigator confirmed no report existed. Internal email communication also showed that police had not been to the facility, and staff did not perform a documented follow-up with law enforcement, resulting in a failure to report the alleged misappropriation as required.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
The facility failed to timely report an allegation of resident-to-resident verbal and physical abuse to the SSA. A resident with intact cognition reported that another resident threw a tray at her, got food on her, got in her face, and threatened to kill her; the resident said she did not feel safe. The other resident had documented physical and verbal behaviors toward others. The Administrator stated the incident was not reported because it was determined not to meet the definition of abuse, and only a verbal investigation was conducted with no documentation available.
Failure to Report Alleged Abuse: A resident with a BIMS score of 14 and diagnoses including chronic respiratory failure, HTN, dementia, psychotic disturbance, mood disturbance, and anxiety reported that a CNA was nasty to her during care. The resident said she wrote a letter about her concerns and gave it to a wound care nurse, but the Administrator first learned of the allegation during the entrance conference and the DON was not aware of any abuse concern involving the resident.
The facility failed to follow its abuse reporting policy by not promptly reporting an alleged resident-to-resident sexual incident to the Administrator and the SSA. A CNA observed two residents in the same bed, with one resident kissing the other on the lips, and stated she reported this to a nurse, later identified by the facility as an LPN, though this was not clearly documented. The ADON learned of the incident two days later and then informed the Administrator, who subsequently reported it to the SSA. Interviews revealed conflicting accounts about which nurse received the initial report and confirmed that the incident was not reported within the required 2-hour timeframe for alleged abuse.
Failure to timely report a resident fall with major injury: The facility did not submit a state reportable within the required 2-hour timeframe after an unwitnessed fall. The resident had intact cognition, required extensive assistance with transfers, and later complained of back and stump pain; ER x-ray showed a T12 compression/burst fracture. The DON confirmed the report was not filed because she was unaware of the fracture, and an LPN knew of the injury but did not notify her.
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