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.
Failure to thoroughly investigate an allegation of sexual abuse: A resident with severe cognitive impairment and extensive ADL/toileting needs reported being sexually abused at night, but the concern was not immediately escalated to the DON or fully investigated. Staff interviews confirmed the allegation was handled informally, with the resident’s daughter reviewing a camera and saying nothing wrong happened, while facility policy required immediate reporting and an internal investigation.
Two residents with cognitive and mobility impairments experienced alleged verbal, mental, and physical abuse, as well as neglect of care, by nursing assistants. Facility staff failed to promptly investigate, report to the State Agency, or implement resident protections, and did not suspend the alleged perpetrators or conduct thorough interviews with other staff or residents. Documentation and communication gaps were identified among the administrator, DON, and other staff, resulting in incomplete investigations and lack of timely action.
A facility failed to thoroughly investigate an allegation of physical abuse when a cognitively intact resident was punched by a nursing assistant during care. Although staff interviews were conducted, no residents or families were interviewed about the incident, and the investigation did not include residents from other units where the staff member had worked. The facility's policy requiring comprehensive interviews was not followed.
Failure to Protect Resident Funds and Follow Meal Supervision Care Plan: A resident with dementia and severe visual impairment had large amounts of cash kept in his room, but staff did not secure the money in the facility safe, did not maintain documentation or a ledger, and did not complete a full investigation after he accused a staff member of taking his funds. In a separate incident, another resident who required supervision and assist with meals choked while eating alone, and staff and leadership acknowledged the care plan was not followed and the event was not immediately investigated or reported.
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