Staff failed to timely report multiple allegations of abuse, neglect, misappropriation, and resident rights violations, including claims that a former CNA had sexual contact with residents for money, staff sold drugs to residents, and property was taken from a deceased resident. A resident also reported that an LPN did not complete ordered blood sugar checks and insulin coverage on time, and another resident was told to leave a unit or police would be called while he was calm and speaking with an RN. These events were known to staff and residents but were not reported to management or investigated before survey review.
Failure to Timely Report Allegation of Abuse: Staff did not immediately report an allegation of abuse involving a resident with dementia and an LPN. The LPN reportedly grabbed the resident’s wrists, pinned them to the wheelchair arms, and told the resident, "If you hit me, I will hit you back and call the police." Another LPN and an RN both learned of the incident but did not report it to the DON or Administrator at the time, despite facility policy requiring immediate reporting of abuse allegations.
The facility failed to timely report an allegation of neglect involving a resident who was missing after staff could not locate him and initiated the missing resident protocol, including contacting police. The resident had schizophrenia, DM2, and depression, and was moderately cognitively impaired but independently mobile. The SRI was not filed until several days later, despite the facility policy requiring possible abuse and neglect to be reported to the state agency in the appropriate time frame.
Failure to report an allegation of misappropriation: A resident with cerebral infarction, epilepsy, and COPD reported missing $250, but the grievance form had no documented actions or resolution and the allegation was not entered on the SRI log or reported to the state agency. An LPN said she completed the grievance form and gave it to the social worker, and the LSW said he received a voicemail about the missing money but did not document further or notify the Administrator or state agency.
Failure to Report Alleged Abuse: The facility did not submit an SRI to the state agency after receiving a video alleging verbal abuse of a cognitively impaired, ADL-dependent resident. The Administrator heard yelling from the resident’s room, identified an LPN and a CNA in the room, and reviewed video showing the LPN yelling expletives toward the resident, but no report was created because the Administrator did not believe the situation was abuse.
Failure to Report Missing Controlled Substances: The facility failed to report missing controlled meds designated for destruction as misappropriation to the state agency after an internal investigation found the drugs were absent and there was no evidence of destruction. The missing opioids involved multiple residents, and the RCD and Administrator stated the event was reported to other boards but not as an SRI to ODH.
Failure to Report Allegations of Staff-to-Resident Abuse: Multiple residents and staff reported that an LPN was rude, mean, had a bad attitude, and refused care, and several residents would not allow the LPN in their rooms. HR confirmed the LPN was suspended due to resident complaints, and the DON confirmed a resident’s family member reported rude behavior. However, the facility did not submit a self-reported incident to the State Agency as required by policy.
Failure to Report Alleged Verbal Abuse: A resident with hemiplegia and hemiparesis reported that a CNA cursed at her, made her cry, and left her feeling bad and stressed. The DON was notified and said an investigation was needed, but no SRI was opened or submitted to the State Agency for the abuse allegation.
A resident with multiple chronic conditions had a wallet containing a credit card and driver's license go missing, and the wife said she reported it to a CNA and an LPN, but management was not notified. The Administrator, DON, and SSD were unaware of the missing wallet when the issue was raised by the surveyor, and no SRI was initiated at that time. The facility did not report the allegation of misappropriation timely to the state agency, despite policy requiring immediate communication and reporting within 24 hours for allegations not involving abuse or serious bodily injury.
Failure to Report Misappropriation of Residents' Oxycodone: An LPN tested positive for Oxycodone without an active prescription after being required to complete a urine drug test tied to an earlier incident. The facility continued the original investigation instead of opening a new report for the separate misappropriation event, even though multiple residents had Oxycodone orders and were identified as affected. Facility policy required immediate reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident property.
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