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.
Failure to Investigate Possible Resident-to-Resident Sexual Abuse: Two residents with severe cognitive impairment were repeatedly found unclothed together, but the facility did not assess either resident’s capacity to consent or complete a formal abuse investigation. The record also showed bruising and a report of bloody vaginal discharge for one resident, and staff, including the DON, stated no assessments or investigations were completed and the encounters were assumed to be consensual based on the residents’ behavior.
The facility failed to complete thorough abuse investigations after two resident-to-resident altercations involving one resident who struck and scratched other residents. Staff initiated monitoring and safety checks and one incident was witnessed by activity staff, but the investigative files did not include interviews with other residents to determine whether additional residents had also been abused. The DON acknowledged that those interviews were not done.
A resident with stroke-related deficits, impaired cognition, and extensive care needs reported that an LPN inserted his finger into her anus during bowel care and continued despite her crying and asking him to stop. The family also reported the procedure was painful and distressing. The facility’s response was incomplete: the DON was not aware of an earlier progress note about the family’s complaint, no immediate rectal assessment was done, the initial body audit did not include the peri-rectal area, and resident interviews were delayed and limited to only a small sample of residents.
The facility failed to conduct a thorough investigation of a resident-to-resident sexual abuse allegation after a nurse observed a resident with dementia place his hand under another cognitively impaired resident’s shirt and touch her breast in a TV lounge. Although both residents had care plans identifying vulnerability and the need to report suspected maltreatment, the facility’s internal investigation did not include comprehensive interviews with all involved and potentially knowledgeable staff, such as the witnessing RN, the assigned RN, and a NA who had assisted and seated the residents, nor were other nearby residents interviewed. The DON and Administrator, who were responsible for the investigation, could not provide documentation showing that required elements of the facility’s abuse investigation policy—such as full staff and resident interviews and complete assessment of the circumstances—were completed.
A resident with diabetes and multiple comorbidities experienced a medication error when rapid-acting insulin Aspart was administered at an incorrect time and then documented inconsistently by two RNs on the eMAR. Blood glucose readings and eMAR entries showed high glucose levels with 15 units of Aspart recorded at midday and later in the day, while one RN reported actually giving the insulin mid-afternoon and instructing another nurse to chart it as given earlier. That evening, the resident was found weak, cold, clammy, incoherent, and hypoglycemic, was treated with juice, and then sent to the hospital, later becoming unresponsive. The RN involved reported the error to the DON, but the DON and Administrator acknowledged that no medication error form was completed, no clear investigation was conducted, no re-education was provided, the incident was not reported, and no investigation policy was produced when requested.
A resident with dementia, spinal cord disease, repeated falls, and smoking-related care plan interventions fell from his wheelchair in the smoking area and was sent to the ED after nasal bleeding. The incident record noted the fall and immediate response, but no witness statements, follow-up notes, root cause analysis, or care plan changes were documented. The RN was unsure if an RCA had been done, and the DON confirmed the investigation was not thoroughly documented and that staff had not received education on falls, smoking, or smoking during inclement weather.
A resident with dementia, depression, psychotic disorder, and moderate cognitive impairment, dependent on staff for all cares, was allegedly subjected to verbal and physical abuse by a NA during evening cares, including aggressive, profane language and an open-hand smack to the bare buttock while the resident cried and whimpered. Two staff members reported the incident to a charge LPN that evening, but the LPN did not immediately notify the on-call nurse, did not ensure the resident’s immediate safety, and did not document or complete a timely skin or behavior assessment. The alleged abuser continued working with residents until the next morning, and when the investigation was later initiated, it was limited to interviews of a small number of verbally responsive residents, without documented skin checks or behavior chart reviews for non-verbal residents and without interviewing all relevant night staff, contrary to the facility’s maltreatment reporting policy.
Incomplete Investigation of Alleged Abuse and Neglect: The DON did not thoroughly investigate multiple allegations that a nursing assistant was rough during cares, failed to provide privacy, did not knock before entering rooms, and ignored resident concerns. Residents involved had significant care needs and impaired cognition, and staff had already documented repeated complaints, but the investigation only included limited resident interviews and a phone call with the nursing assistant, without interviewing the reporting staff or other witnesses as required by policy.
Failure to Investigate Illegal Drug Incident: Staff found a resident very unsteady after a fall and later discovered a crystal-like substance in his room that police field tested as methamphetamine. Law enforcement interviewed the resident, who admitted possession and said another resident gave it to him, and officers also found a pipe and lighters plus additional drugs/paraphernalia near the smoking area. Facility leadership acknowledged no incident report was completed for the drug event and no further investigation was done, despite resident council concerns about drugs and alcohol in the facility.
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