The facility failed to report multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia, anxiety disorder, and chronic respiratory failure. Emails from the resident’s daughter to facility staff and the state agency described an LPN allegedly giving Tramadol doses too close together, intimidating the resident, not administering ordered meds, falsely documenting refusals, and ignoring incontinence care requests, as well as a CNA allegedly disrespecting belongings and speaking to the resident like a small child, another aide allegedly yelling at the resident, and a theft of socks. These concerns were not documented in the resident’s record or concern log, and only one self-reported incident related to the resident appeared on the state website. The Administrator, DON, ADON, and Regional Nurse denied knowledge of the emailed allegations and confirmed they were not investigated or reported, despite facility policy requiring timely reporting of all such allegations to the state agency.
Two cognitively impaired residents were found in a male resident’s bed with both of their pants down, with a CNA observing the male on top of the female and immediately separating them and notifying an LPN and the DON. The female resident had Alzheimer’s disease with a BIMS score indicating severe impairment, and the male resident had dementia, hepatitis C, antisocial personality disorder, and a documented high-risk heterosexual behavior diagnosis, yet neither had any documented assessment of capacity to consent to sexual activity in their records or care plans. Facility leadership and clinical staff confirmed the physical circumstances of the incident, acknowledged that both residents were considered unable to consent based on BIMS scores, and confirmed that no report was made to the state survey agency, no SRI was filed, law enforcement was not contacted, and the male resident’s guardian was not consulted about police involvement. Review of facility policies showed requirements to evaluate capacity to consent when there is reason to suspect a resident may lack such capacity and to report alleged abuse and investigation results to the state survey agency within specified timeframes, which were not followed in this case.
A cognitively impaired, wheelchair-dependent resident with multiple chronic conditions developed new, red, quarter-sized, symmetrical discoloration on both cheeks, identified during a skin assessment by an RN after prior documentation that the resident would not open her mouth for medications. The RN notified the DON, hospice, and the resident’s family, but no self-reported incident was filed and no investigation or report to the State Survey Agency was made. The DON stated she assumed the discoloration was self-inflicted based on the resident’s history of flailing, and the incident was not treated as an injury of unknown origin, contrary to the facility’s abuse prevention policy requiring such injuries to be reported and investigated.
The facility failed to timely report multiple instances of misappropriation of resident trust funds, where several cognitively impaired and cognitively intact residents had unauthorized online purchases made from their accounts by former business office, activities, and social services staff. Items such as clothing, electronics, personal care products, snack foods, and dementia activity supplies were ordered without resident or representative consent, often without required documentation or signatures, and some items were never received by the residents and were instead found in the activities department. An activities staff member observed large quantities of goods ordered under resident accounts being stored and used in the activities area, suspected misappropriation, but did not report these concerns to the Administrator, DON, or corporate office, contributing to delayed reporting of these abuse allegations to the state agency as required by facility policy.
A resident with NASH, diabetes, ascites, obesity, and intact cognition was care planned as full code with interventions for CPR, 911 activation, and Q2H turning and repositioning. During a night shift, an agency CNA assigned to the resident was frequently unavailable and reported by staff as not tending to residents’ needs or following up on care requests. The CNA stated he last checked the resident between midnight and 1:00 A.M. and did not check again before an LPN found the resident unresponsive, cool to touch, and without vital signs during morning med pass, later verified by an RN. Staff interviews confirmed an expectation for resident checks every 1–2 hours, and the DON acknowledged the resident was not checked or cared for in a timely manner and that an extended period without checks would be considered neglect. Despite this, no self-reported incident of suspected neglect related to the resident’s death was submitted to the State agency, contrary to facility policy requiring immediate reporting and investigation of alleged abuse or neglect.
A dependent, cognitively impaired resident with multiple comorbidities was found on the floor of her room, after which family, the CNP, and the DON were notified and x‑rays were obtained that initially showed no fractures despite ongoing pain. Subsequent imaging revealed a cortical breach of the femoral neck and later a CT confirmed a nondisplaced right intertrochanteric femur fracture, with the DON unable to determine whether it was related to the fall or occurred during routine care and acknowledging it was an injury of unknown origin. The DON confirmed that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency as required by facility policy and federal regulations.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for all ADLs, was transported by a facility driver to an outside cancer treatment appointment. Staff at the treatment center reported that the transporter appeared upset, stated he was having a bad day with the patient, and was observed within inches of the resident’s face, flailing his arms and yelling, leaving the resident visibly upset. The incident was reported to the Ombudsman, who then informed facility leadership during a video conference. Despite this notification and the facility’s abuse policy requiring reporting of alleged abuse to the state agency within a specified timeframe, the allegation of staff-to-resident verbal abuse was not reported to the state agency until several days later, resulting in a failure to timely report suspected abuse.
Two moderately cognitively impaired residents sharing a room, one with left-sided hemiparesis, anemia, and on aspirin therapy, were involved in a physical altercation after ongoing conflict over TV volume. One resident later reported that his roommate came through the privacy curtain and hit him while he was in bed, and staff interviews indicated the aggressor had a history of verbal/physical aggression and admitted to slapping the other resident on the head or shoulder. Initial documentation by the DON, who was not on-site, characterized the event as only a verbal dispute, and the Administrator was informed there was no physical contact, so the incident was not promptly reported to the state agency. There was no timely documentation of physician or family notification, no immediate staff statements were obtained, and no investigation was completed within the facility’s abuse policy timelines, despite later observation of bruising on the injured resident and subsequent grievance interviews confirming physical contact.
A facility failed to timely report an allegation of verbal abuse to the state survey agency after a severely cognitively impaired hospice resident with dementia and behavioral disturbances was subjected to raised voice and hand-clapping in the face by a CNA during care, which another CNA viewed as verbal abuse and reported to the DON by text. The accused CNA later wrote a statement describing the hand-clapping as an attempt to calm the resident, and an LPN stated she did not witness aggression, but the facility’s file contained only limited documentation and no complete investigation or body assessment. Staff interviews revealed that multiple residents had requested not to receive care from this CNA, and that the CNA had previously been escorted out and suspended for unacceptable behavior toward staff, with residents describing the CNA as loud and confrontational. The DON acknowledged not obtaining the requested witness statement and determining the incident was not abuse, and the Administrator acknowledged that an SRI was not initiated as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident with dementia and multiple chronic conditions was found by an NP to have a swollen upper lip with dark purple discoloration, with conflicting explanations from the resident and staff and no clear source of injury. Although the NP ordered monitoring of the injury, there was no subsequent documentation by staff of monitoring or assessment in the chart, and the skin assessment did not reflect the lip injury. The DON confirmed that no investigation was conducted, no staff or resident statements were obtained, and no self-reported incident was submitted to the state agency, despite facility policy requiring investigation and reporting of injuries of unknown source.
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