Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
The facility failed to thoroughly investigate allegations of abuse and an injury of unknown origin involving one resident with severe cognitive impairment who was later found to have rib fractures, and two residents who were observed hitting each other and sustained scratches. Required staff statements were not documented, the injury was not concluded to be abuse, neglect, or unknown origin, and video surveillance was not reviewed during the resident-to-resident incident investigation.
Incomplete investigation of an unwitnessed resident fall with injury: A cognitively intact resident with muscle weakness and gait/mobility impairment was found on the floor with head swelling, nasal bleeding, and knee redness after an unwitnessed fall. The incident review lacked a statement from the LPN who reported the fall, and the CNA form was not clearly attributable to a specific CNA because the name was missing and the signature was illegible; later staff interviews did not clarify the event.
Inaccurate abuse investigation summary: A resident with vascular dementia, anxiety, depression, and a history of trauma accused staff of abuse after becoming upset when a CNA redirected the resident from another resident’s room. Police responded after the resident called 911, and the investigation was found not substantiated; however, the RN supervisor’s statement listed the wrong incident date and incorrect CNA initials, and the DON and Administrator said they were responsible for reviewing the summary for accuracy.
Failure to Thoroughly Investigate Alleged Neglect Involving Blood Sugar Checks: The facility did not maintain documentation showing a thorough investigation of an alleged neglect incident involving two residents and an LPN who reportedly did not complete blood sugar checks. The incident summary lacked staff statements and detailed interviews, and the Administrator could not locate the reported investigations. Staff interviews described unreliable glucometers and recalled the allegation, but the facility could not produce the full investigation record.
The facility failed to thoroughly investigate two allegations involving residents: a missing cell phone and a report that an aide was rough and pushed a resident into a wheelchair. Records and interviews showed no clear grievance file, resident or staff statements, or documented investigation for either event, despite family reports and staff awareness of the incidents.
Incomplete investigations of resident injuries and alleged abuse: The facility did not thoroughly investigate three incidents involving residents with dementia and severe cognitive impairment. One resident punched a window and sustained lacerations and a fractured finger, but the file lacked documented statements from interviewed residents and all staff on the unit. Another resident alleged being pushed after a fall, yet recreation staff wearing red coats were not interviewed despite matching the resident’s description. A third resident had an unexplained thigh bruise, but the investigation had no summary, conclusion, or findings to determine the cause or rule out abuse, neglect, or mistreatment.
A resident with severe dementia and high fall risk was found on the floor after an unwitnessed fall and later returned from the hospital with a hip fracture. The incident record concluded there was no reason to suspect abuse, neglect, or mistreatment, but the investigation only included statements from the assigned CNA and one LPN. Interviews showed other staff were on the unit at the time, and the RN, ADON/Risk Manager, and DON acknowledged that statements from all staff working on the unit were not obtained.
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to Investigate Resident Injury After Altercation: A resident with dementia, pulmonary fibrosis, and anxiety was pushed to the floor by another resident and sustained a humeral fracture. After returning from the hospital, the resident later developed worsening hip pain, was found to have an acute femoral neck fracture, and underwent hemiarthroplasty. The facility did not complete an incident report or a thorough investigation to determine the cause of the fracture or whether it was related to the earlier altercation.
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