Failure to follow the abuse reporting and protection policy after an allegation of staff-to-resident physical abuse involving a nurse and a resident with multiple serious diagnoses. Staff described seeing the nurse pull and drag the resident in the hallway, but concerns were not reported to leadership right away because of fear of retaliation and belief the nurse was a valued employee. The facility did not learn of the allegation until a CNA brought photographs to the Administrator and DON, and the nurse was suspended only after that disclosure.
Failure to Report and Investigate Abuse, Injury of Unknown Origin, and Improper Restraint Use: A resident with dementia developed an unexplained wrist/forearm fracture that was not reported to the Administrator or outside agencies, and two separate resident-to-resident abuse incidents involving two cognitively impaired residents were not properly reported to the state or APS. The facility also delayed a full abuse investigation after staff were accused of placing gait belts on two residents and continued allowing the implicated employee to work without protective measures.
Failure to Immediately Protect and Report Resident Abuse: Agency staff were observed verbally abusing a resident, aggressively pushing the resident's wheelchair, and striking the resident in the back with a closed fist. Witnesses did not immediately intervene or report the incident to the DON/Administrator as required, and the allegation was not reported until the next morning. The resident had dementia and depression, and the investigation later found skin alterations and generalized pain.
A cognitively impaired resident with Alzheimer’s disease, known to be resistive to care, was being assisted with incontinence and dressing care by two NAs when the resident became agitated, grabbed the bed rail, and attempted to bite. One NA responded by striking the resident on the lips with an open hand and stating the resident would not fight or bite them, while the assisting NA, though shocked, continued providing care instead of stopping and intervening. As care and a subsequent transfer to a wheelchair continued, the resident swung at staff, and the same NA struck the resident two additional times—once on the face and once on the back of the head—while repeating similar statements. The assisting NA only removed the resident from the room and reported the incident after completing the transfer, later acknowledging she should have stopped care and removed the other NA after the first strike, demonstrating a failure to follow the facility’s abuse prevention and immediate reporting policy.
A resident alleged that staff threw mashed bananas and ice water on her after she had thrown a banana at a nurse. An NP observed the resident wiping water from the floor and was told by the resident that staff were throwing things at her, then notified a nurse manager, who in turn notified the DON and Administrator. The Administrator asked a rehabilitation manager to investigate, and interviews with staff and the resident confirmed that a banana and water had been thrown on the resident, though specific staff were not identified by the resident at that time. Despite facility policy requiring immediate reporting of abuse allegations to the State Survey Agency, law enforcement, and APS, the initial allegation report to the State Survey Agency and law enforcement was not made until two days later, and there was no documentation that APS was notified. The DON later stated she was unaware of the requirement to report the allegation to APS, and leadership acknowledged the allegation was not reported within the required timeframe.
Two residents were involved in a physical altercation in a common area, during which one resident was reportedly struck in the face by another while a third resident encouraged the aggression. CNAs observed the incident, separated the residents, and notified the nurse, but the RN on duty did not immediately notify the Administrator despite acknowledging she should have. The weekend Administrator on Duty learned that one resident may have hit another and that the alleged victim reported being hit by a man, yet the incident was still communicated to the Administrator as a non‑physical, verbal altercation. A written CNA statement describing the hitting was not reviewed by the Administrator for several days, the DON was not promptly informed, law enforcement was not notified within 24 hours, and key witnesses were not interviewed in a timely manner, resulting in delayed and incomplete implementation of the facility’s abuse reporting and investigation procedures.
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting and investigation when a pharmacy reported missing Oxycodone tablets from a sealed controlled medication return bag for a discharged resident. An ADON did not promptly return the pharmacy’s initial call, then delayed notifying the DON after being informed of the missing narcotics, and the DON further delayed notifying the Administrator. During this time, nurses associated with the narcotic returns continued to work, and notification to law enforcement about the missing narcotics was delayed and not clearly documented. These delays resulted in the Administrator not being immediately informed of the allegation of misappropriation of narcotic medication as required by facility policy.
A resident with dementia was allegedly struck on the side of the head by a nurse aide, but the witnessing NA did not report the incident at the time, despite believing it could be abuse. Months later, the NA informed an agency nurse, who also failed to notify facility leadership as required by the abuse policy and instead only contacted APS after her shift. Facility policy required immediate reporting of all abuse allegations to the Administrator and other agencies within specified time frames, as well as immediate investigation and protective measures. Due to these inactions, the Administrator and DON were not promptly informed, and the facility’s investigation and protection of the resident were delayed.
Two residents receiving Hydrocodone-Acetaminophen for pain experienced missing narcotic doses after pharmacy deliveries that were signed for by a nurse, with med aides later discovering that medication cards and corresponding control records were absent from the med cart. The DON identified only a small group of staff with access to the cart, interviewed them, and suspended and ultimately terminated the nurse who had signed for the narcotics after she reported no recollection of the missing drugs, but the facility lost or could not produce investigation documentation and could not locate key narcotic control records. Hospice staff for both residents confirmed that the medications belonged to the residents and that hospice did not investigate or report diversion, while the Administrator and DON believed hospice ownership as payer meant the events were not misappropriation from residents and therefore did not report the allegations to the state agency, APS, law enforcement, or licensing authorities as required by facility policy.
A cognitively intact resident with Type 2 DM had two tirzepatide (Mounjaro) pens found empty when a nurse attempted to administer the scheduled weekly injection, requiring replacement medication from the pharmacy and resulting in a delayed dose. The nurse and UM confirmed both remaining pens for this resident were already activated and empty, based on comparison with another resident’s unused pen. Although facility policy required immediate investigation and reporting of suspected abuse, neglect, exploitation, or misappropriation to the Administrator, State Agency, APS, and other agencies, no formal investigation into the empty pens was conducted and no report of potential misappropriation was made to the State Agency or other required entities.
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