Failure to immediately report abuse and resident altercation allegations: Staff did not promptly notify administration after an LPN witnessed possible verbal and physical abuse between a CNA and a resident, instead leaving a note that was not found until days later. Staff also delayed reporting a resident-to-resident physical altercation involving two residents, with the DON learning of it nearly five hours after it occurred, despite policy requiring immediate reporting.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Failure to Report and Investigate Injuries of Unknown Origin: A resident with advanced dementia, severe cognitive impairment, and dependence for all ADLs had repeated unexplained bruising while receiving daily aspirin. The HCP reported frequent bruises on the resident's arms, legs, and thighs without a clear source, and most incident reports and progress notes did not identify an investigated cause. The DON acknowledged that injuries without a known source should have been reported to DPH and investigated as potential abuse, but this was not done.
Failure to Follow Abuse Investigation and Reporting Procedures: A resident with dementia and cognitive communication deficit reported abuse concerns and asked to speak with police, but the DON treated the matter as a misunderstanding related to CNA positioning with pillows. The facility did not fully initiate its abuse investigation process, did not interview additional staff or residents beyond the CNA and roommate, and did not report the allegation to the state agency or police.
The facility did not follow its abuse screening policy requiring a Massachusetts Nurse Aide Registry check for all employees prior to hire when a contracted occupational therapist was employed without documentation of this background check. Review of the personnel file showed no evidence that the registry check was completed before the therapist’s start date, and the DON confirmed during interview that the contracted staff member had not been screened through the Nurse Aide Registry as required by facility policy and contract.
A resident with dementia, severe cognitive impairment, and behavioral disturbances, care-planned for mood alterations and agitation, was involved in an incident where a CNA responded to the resident’s insult by repeating the same derogatory phrase back to the resident in a loud manner. Another CNA witnessed this exchange but did not immediately report it, waiting several days before informing supervisory staff, citing confusion about how to report when the DON and Administrator were not on-site. During this delay, the alleged perpetrating CNA continued to work multiple shifts. When the allegation was finally brought forward, it was not relayed to the DON immediately, further delaying appropriate administrative awareness, contrary to the facility’s policy requiring immediate reporting of all abuse allegations.
Staff failed to follow the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. In one case, a resident with dementia and other conditions cried out that he/she had been slapped during a transfer, and a nurse heard a slap and the resident’s statement but allowed the CNAs to continue care and delayed reporting the allegation to a supervisor. In another case, a resident with TBI, morbid obesity, and major depressive disorder was allegedly subjected to repeated verbal abuse by a hospice aide, including being called a pig and fat, while CNAs who witnessed these incidents did not report them at the time and one initially denied knowledge when questioned, only disclosing the abuse later during an investigation.
A resident with dementia, severe cognitive impairment, and dependence on staff for care was allegedly handled roughly by a CNA, resulting in bruising to the resident’s arms, according to the resident’s family. A nurse heard the family member loudly accuse the CNA of abuse but did not report the allegation to a supervisor or administration. The weekend Nursing Supervisor was later informed by the same family member that the CNA had not properly cleaned the resident and was believed to be responsible for the bruising, yet she did not immediately notify the administrator or DON as required by the facility’s abuse policy, instead leaving a written statement under the administrator’s door. As a result, the administrator did not learn of the alleged abuse until informed by police, demonstrating a failure to follow the facility’s mandated immediate abuse reporting procedures.
Failure to Follow Abuse Reporting and Investigation Policy for Alleged Sexual Abuse: A CNA reportedly found a resident leaving another resident’s room with exposed genitals, and the event was reported up the chain of command. The DON said she directed staff to contact police and document statements, but the Administrator decided no further action was needed because the residents were friends. The resident’s guardian said he was told the resident had been molested and that police came to the facility, but the medical record did not document the alleged sexual abuse event or related police involvement. The Administrator later acknowledged the facility should have followed its abuse policy and reported and investigated the allegation, but did not.
A resident with depression, diabetes, and moderately impaired cognition alleged that a CNA slapped him/her during feeding. The resident and spouse reported the concern to staff, but the record showed the accused CNA continued to provide care during the shift, the allegation was not clearly documented in the chart, the SW was not documented as providing follow-up support, and the facility’s abuse investigation process was not carried out as described by the DON and NHA.
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