Incomplete investigations of alleged abuse and neglect were documented for multiple residents. The facility failed to obtain resident and staff statements, did not interview witnesses or other involved staff, and in one case did not submit the required follow-up report to OHCQ. For another resident alleging rape and assault, several staff on the relevant shifts were not interviewed or documented, and for a resident alleging abuse, the NHA could not produce the initial report, 5-day report, or investigation.
The facility failed to ensure post-incident abuse education included all staff involved in or present during an allegation of physical abuse toward a resident. Although in-service training was completed after the incident, staff on the shift when the allegation occurred were not listed as educated on abuse recognition, reporting, and prevention. The DON agreed that all staff, especially those potentially involved, should be included in post-incident education.
Incomplete investigations of neglect allegations: The facility concluded two neglect allegations were unsubstantiated even though resident interview and observation forms were left blank in the investigation files. In one case, a CNA was alleged to have told a resident to go in a brief instead of assisting with toileting; in the other, a resident’s sister alleged neglect involving oral hygiene, hair hygiene, incontinence care, nutrition, and staffing. The ADON acknowledged the records did not show that the investigations were completed thoroughly before the conclusions were made.
Incomplete investigation of alleged verbal abuse: A family member reported an hour-long delay in pain med administration, and an LPN allegedly argued and made a statement about people in America wanting things done immediately. An RN witness confirmed the statement, but the investigation omitted the RN’s account and a resident’s comment that the LPN was snappy, and the report concluded the allegation could not be verified based on other resident interviews and the LPN’s explanation.
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.
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