A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a shared landline phone and threatened to kill her and her sister, with the sister confirming she overheard these threats. The resident told a CNA and was moved to another room, but later reported that the roommate continued to intimidate her by making finger gun gestures when passing her door. The SSD was notified by a CNA of verbal threats and filed an APS report, but did not clearly ensure that the DON was informed or that staff were interviewed about ongoing gestures. The DON believed the incident involved only a phone altercation with the sister, concluded there was no resident abuse, and therefore did not initiate an investigation or report the allegation to the state agency, resulting in a failure to document, report, and thoroughly investigate the verbal abuse allegation.
The facility failed to complete and maintain required written statements during an abuse investigation after a resident with Down Syndrome witnessed a verbal argument between a QMA and a CNA. The investigation file contained an incident report and a written statement from the QMA, but no written statement from the CNA, despite the CNA reporting that she had submitted one. The ED stated the CNA’s input was obtained verbally and over the phone and was not documented as a written, signed, and dated statement as required by the facility’s Abuse Prevention Program policy and state regulation.
Failure to Remove Alleged Abuser After Abuse Allegation: Staff heard reports that a CNA may have put hot sauce and/or soap in a resident’s mouth and threatened to wash her mouth out with soap, but the CNA was allowed to keep working with resident contact for about three hours before the Administrator was notified. An LPN and another CNA heard the rumors and observed concerning statements and items, while a second LPN did not intervene or report the allegation immediately. The resident had vascular dementia, depression, anxiety, and GERD, and her representative stated the act would have been viewed as abusive and punitive.
The facility failed to thoroughly investigate multiple resident-to-resident abuse incidents involving one cognitively impaired resident who repeatedly pushed other residents, causing falls and, in one case, injury requiring ER transfer. Several residents with dementia and mobility or cognitive impairments reported or were documented as being pushed, resulting in loss of balance and falls. Facility documentation focused on falls and environmental or behavioral interventions, but the investigation files provided by the Administrator lacked abuse investigations for these altercations, even though the Administrator acknowledged being informed of at least one pushing incident.
A resident with severe cognitive impairment and multiple comorbidities had a care plan including video monitoring and a STOP sign at her doorway. A male resident entered her room on more than one occasion, including an incident captured on family-installed cameras where he approached her bed while she slept, opened his robe, and ultimately sat on her chest and shoulder, causing her to cry out in pain before staff removed him. The resident’s representative reported this allegation to the Administrator by email, but the facility did not complete a thorough abuse investigation as required by its policy to investigate all alleged violations reported by residents or relatives.
A resident with severe cognitive impairment, high fall risk, and wandering behavior was observed by his spouse and later by surveyors with a swollen, darkly bruised eye, while staff reported they did not know the cause and had no immediate plans for further testing. Documentation noted the puffed, dark eye but lacked any assessment of VS, neuro status, or the orbital area, and there was no evidence of timely notification of the physician, leadership, or the spouse. The DON learned of the injury days later, was unsure who discovered it, and although a risk management entry was made, no prompt interviews or investigation were completed, contrary to the facility’s policy for unexplained injuries.
Failure to Thoroughly Investigate Abuse and Misappropriation Allegations: The facility did not fully investigate or document alleged resident-to-resident physical abuse, sexual abuse, and misappropriation of a resident’s funds. Records and interviews showed incomplete incident investigations, missing IDT notes, lack of care plan revisions, no documented follow-up for resident monitoring or supervision concerns, and incomplete follow-up on safe surveys and staff allegations related to the missing debit card and cash.
Incomplete Investigation of Resident-to-Resident Abuse: The facility failed to thoroughly investigate and maintain records for a resident-to-resident altercation in which one resident accused a roommate of stealing clothing and was yelling at the roommate to leave his closet. Although staff separated the residents and documented no injury, the investigation file lacked staff witness statements, the incident report, and interviews with interviewable residents near the room where the event occurred. Interviews showed nearby CNAs had written statements, but an LPN later had to be asked to provide one and another LPN said she had not received any statements.
A facility failed to thoroughly investigate an abuse allegation after a resident with severe cognitive impairment and multiple disabilities was reported to have been inappropriately touched by staff. The investigation was limited to a physical assessment and did not include interviews with other staff or residents, nor was the incident documented in the resident's record or communicated to the family.
Two residents with cognitive impairments were involved in separate incidents of alleged sexual abuse by another resident with intellectual disabilities. Staff observed inappropriate situations, including exposure and possible sexual contact, but did not follow proper investigative protocols or protective interventions. Documentation was incomplete, communication among staff and leadership was inconsistent, and the facility failed to report the incidents as sexual abuse to the state. Family members learned of the events through anonymous calls, raising concerns about transparency and adherence to abuse prevention policies.
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