A facility failed to identify and thoroughly investigate multiple grievances alleging verbal abuse, rude and unprofessional comments, and threats of involuntary seclusion by an RN and an LPN toward several residents. The record shows repeated complaints that staff yelled at residents, blocked a resident from entering his room, and used a “time-out” approach, but the facility often interviewed only the directly involved parties, left grievance sections blank, did not document timely reporting to the administrator and SA, and did not remove the staff from direct care pending investigation.
Failure to investigate resident-on-resident abuse and unexplained perineal injury: A cognitively intact resident reported being frightened after another resident repeatedly entered her room, grabbed belongings, and snarled at her, but leadership did not complete a formal abuse investigation. The facility also did not investigate a cognitively intact resident’s unexplained labial/perineal tear after an ER visit, despite the injury being documented as a laceration of the perineum and staff acknowledging the concern was discussed but not reported or investigated.
Incomplete investigation of alleged sexual abuse: The facility failed to thoroughly investigate an allegation that a cook had a sexual relationship with a resident who had multiple psychiatric diagnoses and was cognitively intact. The DON and administrator were notified by two residents, but the resident witnesses were not interviewed, the resident’s chart lacked documentation of the allegation and related communication attempts, and the cook denied the allegation. The DON did not file a police report, and the allegation was concluded to be unsubstantiated without a thorough investigation.
Failure to Thoroughly Investigate Alleged Staff Drug Use and Neglect: A NA reported seeing an LPN smoking what appeared to be methamphetamine in his car while on duty and said he took excessive breaks and may have missed resident care, including not checking on a resident with abdominal pain. The DON, administrator, and RN reviewed a grainy video and concluded it was unclear, but the facility did not drug test the LPN, suspend him, interview residents or additional staff, review controlled meds for diversion, or involve law enforcement at the time of the allegation.
A resident with PTSD, depression, anxiety, and heart failure was the subject of two abuse allegations involving a staff member shaking the resident and another staff member threatening to hit the resident. Family emails reported the concerns to the DON and RN-B, but the investigation was limited: only the resident and the alleged perpetrator were interviewed for one allegation, no other staff or residents were interviewed, and the staff member remained able to care for other residents.
Failure to thoroughly investigate an unexplained ankle fracture: A resident with impaired cognition, osteoporosis, and anticoagulant use developed bruising, swelling, and pain after difficult transfers and bed mobility. Staff described a transfer in which the resident was moved quickly and ended up near the edge of the bed with her legs and feet dangling, and the next day she was found with a bruised calf and swollen ankle. The ED confirmed a nondisplaced ankle fracture, but the facility did not interview all relevant staff or fully review the events leading up to the injury.
Failure to investigate and protect residents from resident-to-resident abuse: A resident with severe dementia, aphasia, and repeated aggressive behaviors repeatedly entered other residents’ rooms and physically assaulted multiple residents, including pushing one resident’s wheelchair into a post, striking residents, grabbing an arm, and hitting another resident in the face. Staff documented many events in progress notes, but only one incident report could be located, and interviews showed staff were unsure about reporting requirements and relied on informal interventions such as 1:1 supervision, closing doors, and placing stop signs on room doors.
Failure to immediately protect a resident after witnessed abuse: an RN allegedly used profanity toward a resident with significant cognitive and physical impairments and abruptly stopped supporting the resident’s weight, causing the resident to fall backward into the bed. An LPN and a nursing assistant witnessed the event, but the RN remained in charge and continued caring for residents for about four hours before being replaced. The DON and administrator both stated the RN should have been removed from duty right away, and the facility’s abuse policy lacked clear operational direction for immediate protective action.
Failure to thoroughly investigate alleged physical and verbal abuse and protect a vulnerable resident. A non-verbal resident with cognitive impairment and limited mobility was reportedly roughly handled during cares and subjected to demeaning comments by a CNA. Staff delayed reporting the allegation, the resident was not fully interviewed using alternate communication methods, no incident report was completed, and the CNA continued working regular shifts without removal or direct supervision while the allegation was reviewed.
Failure to investigate and document resident elopement: A resident with severe cognitive impairment, dementia, psychosis, and daily wandering behaviors had a known elopement risk and multiple reported attempts to leave. Staff described the resident getting into an employee’s truck, driving it to the delivery area, and being stopped by the former DON, but the event was not documented, investigated, or reported. The record also lacked documentation of prior elopement attempts and related incident reports, despite staff awareness of repeated events.
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