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.
A resident with severe cognitive impairment and dementia-related behavioral disturbances became frightened during care when a CNA was reportedly rough and rushed, leading the resident to strike the CNA and the CNA to allegedly hit the resident’s thigh. A CNA reported the incident to the DON and Administrator and described being criticized and told she was overreacting, while being required to retake abuse training. The DON did not report the allegation to the state, did not complete a written investigation, and did not document the incident, assessment, monitoring, or notifications in the EHR, despite facility policy requiring formal investigation steps, documentation, and appropriate notifications for suspected abuse.
A cognitively intact resident with paraplegia, seizure disorder, respiratory failure, malnutrition, MDD, antisocial personality disorder, and PTSD alleged physical abuse by a respiratory therapist. Although staff reported promptly notifying leadership and obtaining written statements, the facility’s investigation file contained only limited, unsigned statements and lacked the original witness and resident statements, as well as documentation of additional resident and staff interviews that were later identified. Despite concluding there was no evidence to support the allegation, the facility failed to maintain complete, signed documentation and supporting materials as required for a thorough abuse investigation under its own policy.
Failure to investigate resident-to-resident abuse incidents involving a cognitively impaired resident. A resident with severe cognitive impairment, dementia, anxiety, depression, and a history of aggressive behavior was documented grabbing, pushing, poking, yelling at, and invading the space of other residents. The care plan listed general redirection and monitoring interventions but lacked specific aggression-related protections, and the facility's records did not consistently identify the other residents involved. The DON and Administrator stated they did not complete investigations for some of the incidents, and staff did not assess the affected residents for injury or psychosocial harm.
A resident with cerebral palsy, severe intellectual disability, and severe cognitive impairment, who depended on staff for most ADLs and preferred to stay in the common area, was allegedly placed in his room with the door closed by a CNA so the CNA would not have to hear his vocalizations, and kept there for an extended period despite his apparent wish to leave. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted out, but the RN only mentioned the concern to the DON in passing. The DON and Administrator stated such allegations should be reported directly to them and that the alleged perpetrator should be separated from residents, yet there was no documentation that an abuse investigation was initiated or that the CNA was separated from residents, despite an abuse policy that defined abuse to include involuntary seclusion and required timely reporting and investigation.
Two cognitively impaired residents were observed by a CNA with their hands down each other’s pants at the nurses’ station, after which they were separated and a nurse documented no trauma and notified leadership. The Administrator, relying on second-hand clarification that the residents were only holding hands in a lap and noting both had dementia, decided the incident was not reportable and did not initiate a formal investigation. The DON was not fully informed of the specific allegation, Social Services did not document the event, and no comprehensive abuse investigation consistent with the facility’s abuse/neglect policy was conducted, resulting in a failure to immediately and thoroughly investigate an allegation of potential abuse.
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