Failure to Thoroughly Investigate Sexual Abuse Allegation: A resident with cognitive impairment and significant ADL needs alleged that a CNA touched them inappropriately during care and tried to rape them. The facility’s file contained conflicting resident accounts, staff statements, SBAR documentation, and police-related information, but did not show how those discrepancies were reconciled before the allegation was labeled unsubstantiated. The investigation also lacked evidence of the police report and did not document whether staff questionnaire responses were based on direct observation of the care interaction.
Failure to Investigate Allegations of Abuse: The facility did not ensure all abuse allegations involving a resident were investigated or that the resident was protected from further abuse. A resident was sent to the ED with bruising to the neck, knee, and elbow, and the ED documented an abuse allegation and notified the forensic nurse and police. Interviews showed the DON did not assess the resident or speak with the family, the NHA could not determine the concern, and staff reported additional abuse allegations that were not shown to have been reported to the SA or thoroughly investigated.
Incomplete investigation of alleged misappropriation: Staff did not complete a thorough investigation of a resident’s allegation that a GNA took money in the resident’s presence. The investigation file lacked the unit staffing sheet and statements from a GNA who worked on the unit and the RN supervisor on duty, and the Administrator said staff mainly interviewed whoever was around and went straight to the accused GNA after the resident identified them.
The facility failed to complete a thorough abuse investigation involving a resident who alleged that a nursing assistant slapped them during a bed bath. The investigation lacked head-to-toe assessments for the resident and other unable-to-be-interviewed residents, written statements from the alleged perpetrator and coworkers, and the nursing assistant was not removed from resident care areas as required by policy.
Incomplete investigation of alleged verbal abuse. A resident with intact cognition reported that nurses used inappropriate language, but the investigation packet did not include the resident’s statement. Two LPNs were identified as involved, and there was no documentation of corrective abuse training for either staff member after the incident; the DON confirmed the missing statement and lack of follow-up training records.
Failure to Thoroughly Investigate Allegation of Neglect: The facility did not thoroughly investigate an allegation that a resident was left to feed self with the door closed and spilled food on self. Although the investigation file stated that interviews were completed and skin assessments were done for non-interviewable residents, survey review found no evidence of resident interviews or skin assessments in the records provided, and the NHA and Clinical VP acknowledged the missing documentation.
Failure to Report Substantiated Abuse and Incomplete Abuse Investigations: A resident reported that a GNA threatened and physically intimidated the resident during medication administration, and the facility later substantiated the abuse based on staff statements, but leadership did not report the finding to the nurse aide registry and did not know the reporting process for a credentialed aide. In separate abuse investigations, the facility did not interview all relevant staff and left multiple resident assessment forms blank, including an allegation that a resident was touched in private areas and another report that a GNA said she had been taught to hit a resident.
Incomplete Abuse Investigation: A facility failed to complete a thorough abuse investigation for a resident because staff who worked during the time of the alleged incident were not interviewed. The investigation lacked statements from three GNAs who worked the relevant shifts, even though the Administrator stated the facility’s process was to interview staff based on the timing of the concern and to review all staff who worked with the resident during the relevant period.
Incomplete Investigation of Narcan-Related Incident: The facility failed to thoroughly investigate a self-reported incident involving a resident with opioid dependence, HF, and a history of stroke who became minimally responsive and received Narcan after a provider was contacted. The investigation file lacked witness statements and the provider’s clinical note, and it did not document any review for possible non-prescribed drugs or substances, including no room search or visitor log review despite the resident’s prior substance-related history.
Incomplete Investigation of Abuse Allegation: Facility staff did not complete a thorough investigation of an abuse allegation involving a resident who called police after reporting abuse by a male with weapons. The DON and ADON obtained statements from some staff and interviewed male residents and staff on the unit, but two GNAs who worked during the time of the alleged incident had no documented statements, and the DON could not explain why they were not interviewed.
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