The facility failed to thoroughly investigate two resident abuse allegations. In one case, an altercation with a scratch injury was recorded as an accident/incident, but the final report had no abuse conclusion and the Abuse Coordinator did not interview the residents, observe the injury, or document staff witness statements. In another case, the final report also lacked a conclusion, interview notes could not be produced, and CNAs who were present or witnessed the altercation were not interviewed despite progress notes showing CNA presence.
Failure to thoroughly investigate a resident’s bruise of unknown origin. The resident had a large bruise to the breast/rib cage area, but the chart had no documentation of a bruise, fall, or incident to explain it. The facility’s report conflicted with staff interviews: the RN said she did not witness a pinch during transfer and described the injury as much more extensive than a simple pinch, while the Administrator acknowledged there was no supporting record evidence for the stated cause.
Incomplete abuse investigation report: A resident with advanced cognitive and communication impairments was involved in an abuse allegation after a visitor was observed at her bedside with his pants unzipped and his hand near his penis while placing an object in her mouth. The facility’s final abuse report sent to the state omitted key facts, including the bedside behavior, the family’s request for a rape kit, and the resident’s hospital admission for possible assault, yet concluded there was no credible evidence of abuse.
Failure to investigate resident-to-resident abuse allegations: Staff documented that one resident slapped another resident, later threw water on him, and had repeated aggressive interactions including threats and wheelchair contact, but the record did not show a thorough abuse investigation for all allegations or documentation of increased monitoring after the water-throwing incident. Interviews showed staff knew the residents needed to be kept apart, while the DON and Administrator were notified of the assault but did not initiate an investigation for the later incident.
Failure to Investigate Resident Abuse Allegations: A resident with MH diagnoses, intact cognition, and a care plan noting abuse and suicidal risk reported that another resident hit the resident’s hand, slapped the resident’s face, struck the resident with an umbrella, used verbal abuse, and bent a friend’s fingers backward. Social Services said some allegations were not included in the abuse investigation report, and the ADM stated he was not aware of several of the reported incidents. The facility had no documentation showing it investigated all of the resident’s abuse allegations.
Failure to Investigate Alleged Physical Abuse: A CNA reported that another CNA said she had to hold a resident down in bed and demonstrated grabbing him by the hands. The RN said she notified the DON and Administrator through secure messaging, but the CNA was not suspended and the allegation was not investigated at the time. The DON and Administrator later stated they were unaware of the incident when interviewed, and the resident had been admitted to the facility and later died on hospice.
Failure to investigate an allegation of misappropriation of a resident’s funds. Staff were aware the resident reported missing money and accused the facility of stealing from the resident’s account, but no investigation was started when management was notified. Interviews showed a CNA had taken the resident’s debit card to a store to buy candy, while the DON assumed the Interim Administrator had initiated an investigation and the Interim Administrator stated he did not because he was not aware money was missing. No investigation documentation was provided to the State Agency.
Failure to investigate repeated verbal abuse allegations between two residents. A resident with dementia and another resident with Parkinson’s disease and cognitive impairment had repeated incidents of yelling, name calling, and profanity documented by staff. Multiple staff said the behavior was abusive and had been ongoing for months, and leadership acknowledged that such conduct would meet the definition of abuse, but no abuse investigation was shown for the allegations involving the two residents.
Failure to investigate an allegation of resident fund misappropriation: a former resident reported that a CNA borrowed $2,000 cash while the resident was still in the facility, made partial repayments, then stopped paying and still owed money. The allegation was reported to the MDS nurse and SS, but the RD assumed it happened after discharge and did not investigate, interview the CNA, or check with other residents. The CNA confirmed the loan, and the Administrator stated no investigation had been started until the day of the interview despite the facility abuse policy requiring investigation of any allegation involving misappropriation of property.
Failure to timely report and thoroughly investigate alleged staff-to-resident abuse. A CNA reported grabbing a resident’s wrist and forcibly taking a cigarette during a smoke break, while the resident said the CNA twisted her arm and was rough. The Administrator treated the event as a customer service issue because the resident said she did not feel abused, did not report it as abuse to IDPH, and did not document a thorough investigation. The DON confirmed the facility’s abuse policy required immediate reporting and investigation, but the investigation was not fully documented.
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