Failure to document and investigate abuse and theft allegations: A CNA told a cognitively impaired resident to urinate in her pants, and the resident later said she felt embarrassed because staff repeatedly made similar comments. In a separate incident, a resident alleged a CNA stole coins from her room, but staff did not promptly report or investigate the allegation and instead only kept the CNA away from the resident. The clinical records lacked documentation of both allegations.
Failure to protect a resident with Alzheimer’s disease and moderate cognitive impairment from alleged financial exploitation and mistreatment. The resident’s family reported suspicious bank activity involving the resident’s ex-stepdaughter, who was also the facility Administrator and a POA, along with concerns about medical decision-making and care. APS and facility leadership were informed, but staff did not separate the alleged perpetrator from the resident or initiate immediate protection measures as required by policy.
A facility failed to separate two residents whose capacity to consent to sexual activity was unknown. One resident had severe cognitive impairment, dementia, and behavioral symptoms, while the other had moderate cognitive impairment, sexually inappropriate behaviors, and diagnoses including other sexual disorders and anxiety. Staff documented kissing, holding hands, and touching between the residents, and interviews showed the DON and Administrator treated the relationship as consensual based on enjoyment without obtaining capacity evaluations.
Failure to investigate suspected abuse and neglect: Staff raised concerns that an LPN removed room identifiers, unplugged a resident’s personal phone, and would not let the resident go to bed when asked. The resident had severe cognitive impairment, and the DON and administrator were aware of the concerns, but no formal investigation or documentation was completed before the allegation was reported to the state agency.
Failure to thoroughly investigate an abuse allegation involving a resident with intact cognition. A CNA overheard a dietary aide use a derogatory term toward the resident and make a rude comment after being upset about remaking a meal tray. The DON/Administrator knew the dietary aide had been loud with the resident, but the incident was not fully reported or investigated as required by facility policy.
Incomplete Abuse and Injury Investigations: The facility did not complete thorough investigations for a resident with patterned bruising after care and turning, another allegation involving a CNA’s intimidating and harsh interaction with the resident, and a second resident with an unexplained rib fracture. The records showed the resident reports, staff observations, and limited investigation notes, but the file lacked a full abuse investigation, including a surveyor statement and complete follow-up on staff statements describing harsh or verbal abuse.
Failure to investigate missing controlled medications: A resident with chronic pain and multiple comorbidities had 54 tablets of Hydrocodone-Acetaminophen missing after a med order change. A CMA placed the discontinued narcotic and count sheet at the nurses’ station for destruction, but the meds were later found missing. Interviews showed the DON and admin were not notified in a timely manner, and the police and State Agency were not informed promptly, delaying the investigation.
Failure to Investigate Injuries of Unknown Origin: The facility did not document or complete investigations for two residents with unexplained bruising. One resident with severe cognitive impairment and anticoagulant use had a bruise on the wrist, and another resident with memory impairment, hallucinations, and anticoagulant use had bruising under the eye with pain. The DON and Administrator confirmed the records lacked incident documentation, and leadership stated they were unaware of the bruises when asked.
Failure to Timely Investigate Allegation of Abuse: A resident with intact cognition and diagnoses including hemiplegia, anxiety, and diabetes reported that staff were mean and screamed at her during toileting care, and her roommate also reported that three staff yelled at her. Staff B completed a grievance and said she notified the ADON, but the facility had no documentation of an investigation before the concern was addressed later, despite policy requiring abuse allegations to be reported within 2 hours and investigated with witness statements.
A resident with intact cognition and expressive aphasia alleged that a CNA yelled at her, called her names, took her soda, and pushed her in the chest/shoulder area during incontinence care, while she believed two staff should have been present. Nursing staff and an LPN assessed her and found no physical injuries, and the CNA reported she only held the resident at the waist to prevent a slip and that the resident sometimes "plops" into her chair. The Administrator reported interviewing some staff and several residents on the same hall, but did not obtain written statements, did not interview all staff who worked that night, and some CNAs and residents later denied being interviewed about rough or abusive care. Facility policy required obtaining witness statements from all known witnesses and thorough investigation of abuse allegations, but the limited interviews and lack of complete documentation resulted in an incomplete investigation of the resident’s abuse allegation.
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