A resident with severe cognitive impairment, wheelchair dependence, and extensive ADL assistance needs fell from bed during morning care when a CNA was alone assisting with dressing, despite the care plan requiring two staff members for dressing and repositioning. The resident struck the back of his head and sustained a bleeding laceration. Surveyors also found no fall mats around the bed, and staff interviews confirmed confusion about the resident’s required level of assistance and that the event was an allegation of neglect that should have been reported to the SA.
Failure to immediately report alleged abuse: Staff observed a CNA forcefully feed a resident, continue feeding when the resident was not chewing, grab the resident by the arm, and handle residents roughly. A CNA student and another witness reported the behavior, and the DON stated she did not learn of the allegation until notified by the CNA instructor. Another resident also reported the CNA pushed him down into his chair during care.
Failure to Report Resident Elopement as Neglect: A resident with PTSD, borderline personality disorder, depression, and wandering behaviors was last seen by staff in the early morning and was not discovered missing until hours later. Staff searched the room, facility, and perimeter, contacted the guardian, LE, and ERs, but administrative staff did not consider the event an elopement because the resident had taken belongings as if leaving on pass. The facility did not report the incident to the SA as an allegation of neglect.
Failure to Report Resident Abuse Allegations: A resident with schizophrenia, MDD, and other behavioral symptoms alleged that a nurse placed hands around his neck and that another staff member showed him marijuana and inappropriate pictures. Staff discussed a witness statement with the resident, but the allegation was not reported to the State Agency, and contracted consultant staff did not share the resident’s abuse concerns with facility leadership. Facility admin later stated the incident should have been reported.
Failure to Report Resident Abuse Allegation: A resident stated that an LPN made fun of him, but he feared retaliation and did not report it. The concern was documented in resident council minutes, yet the facility had no evidence it was investigated, resolved, or reported to the SA before survey. Staff also acknowledged they had not reviewed the minutes and should have followed up on resident concerns.
Failure to timely report alleged abuse: A resident with dementia, encephalopathy, and fluctuating cognition had an allegation that his wife slapped him, reported by a CNA who said she witnessed the event and completed a statement. Facility staff later said the allegation was investigated and not substantiated, but the DON/administrative nurse stated it was not reported to the SA because it was reported days later. The facility policy required allegations of abuse to be investigated and reported within required federal timeframes.
The facility failed to report an allegation of abuse to the State Agency after a CMA observed an interaction between two cognitively impaired residents, including one resident being found in another resident’s room with his pants down. The CMA notified an LN, who contacted administrative staff, and an internal investigation was conducted, including interviews with both residents and review of video showing one resident in the other’s room for over a minute before staff intervened. Despite being informed of an incident described as inappropriate touching and having a policy requiring all alleged abuse to be reported, facility leadership, in consultation with corporate, decided not to report the allegation, concluding they could not determine willful intent and that the residents could make decisions about the interaction.
A resident with a DPOA frequently present during care developed significant bruising on the right leg and later bright red vaginal bleeding and labial injuries, which were repeatedly observed and reported by CNAs to RNs/LPNs over the course of a shift. Nursing staff accepted the DPOA’s explanations, attributed findings to therapy, wheelchair use, itching, or yeast infection, did not promptly assess or document all injuries, and failed to recognize them as potential physical and sexual abuse or injuries of unknown origin requiring immediate reporting. Despite additional observations of dried blood, vaginal lacerations, extensive bruising resembling a handprint, abdominal bruising, petechiae, and the resident’s anxious statements, administrative staff, LE, and the SA were not notified within required timeframes, and the resident remained alone in the room with the alleged perpetrator for many hours before suspected abuse was finally reported.
A resident with dementia, Alzheimer's disease, and documented aggressive behaviors was involved in a resident-to-resident altercation in which she grabbed another resident and required redirection and removal from the area. Nursing documentation described the physical altercation and subsequent 1:1 interaction for calming, but staff did not recognize or treat the event as potential abuse. The incident was not reported to administration or the State Survey Agency, and no investigation, incident report, or witness statements were initiated, despite a facility abuse policy requiring immediate reporting and investigation of suspected abuse, including abuse by other residents.
Failure to Report Resident-to-Resident Abuse Allegation: A resident with dementia, Alzheimer’s disease, and significant cognitive impairment pinched another resident, who also had severe cognitive impairment. The event was documented in the chart, but the incident was not immediately reported to the Administrator or the SA, and the investigation record showed the residents’ representatives and key facility leaders were not notified. The injured resident had no visible bruising or redness on follow-up, but the record lacked further documentation of psychosocial follow-up related to the event.
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