Failure to Report Alleged Staff-to-Resident Abuse: A resident with terminal decline, severe cognitive impairment, and end-of-life medication orders was unresponsive when a nurse attempted to give crushed meds mixed with applesauce. The hospice nurse and the resident’s family reported the nurse forced the mixture into the resident’s mouth after being told not to, and the family believed the behavior was abusive. Facility leadership acknowledged the complaint but did not report the allegation to the State Agency at the time or treat it as abuse.
Failure to Timely Report Alleged Misappropriation: A cognitively intact resident reported that $30 in cash was missing from his room after returning from the hospital. The DON/Administrator did not report the allegation to the State Agency in a timely manner, stating he learned of it much later and did not file an SRI because too much time had passed, despite facility policy requiring alleged misappropriation to be reported within 24 hours of the care team being notified.
Failure to report allegation of physical abuse: A resident with dementia, CKD, CHF, anxiety, and a history of falls stated that a CNA pushed her during care, though she appeared confused and gave inconsistent information and no injuries were observed. The allegation was documented in a progress note, but the SRI review showed it was not reported to the State Survey Agency, and the Administrator stated the nurse who documented it did not report it to anyone.
Failure to Report Abuse Allegation: The facility did not report an abuse allegation involving a resident with multiple fractures, dementia, diabetes, atrial fibrillation, weakness, and a history of falls after becoming aware of the complaint. The allegation stated staff woke the resident and placed him in a full hold, injuring his shoulder. The Assistant DON said the facility was unaware of the allegation until the surveyor raised it, and records showed no report was made to the state agency despite policy requiring immediate reporting to administration and ODH.
Failure to Report Allegation of Abuse: A resident with bipolar disorder, anxiety, depression, type 2 DM, mild cognitive impairment, and a guardian alleged that a CNA was rough during care and caused bruising on her legs. The guardian emailed Social Services about the allegation, but the DON and Administrator verified that no SRI was filed at the time because the resident later denied the abuse and no bruising was found on assessment, despite policy requiring immediate reporting of all abuse allegations to the Administrator and ODH.
A resident who was cognitively intact reported that money he had stored in a lock box in the former administrator’s office could not be found after the administrator left. The administrator and SSD confirmed the allegation involved $280, but no SRI was filed and the allegation was not reported to the state agency, despite facility policy requiring reporting of misappropriation.
Failure to immediately report alleged abuse. A CNA reported that another CNA was rough during transfers and when placing a resident with dementia and severe cognitive impairment into a recliner on the secured memory care unit. The reporting CNA said she believed the incident was abusive but delayed reporting because she was new, unsure how to proceed, and afraid. The DON verified the allegation should have been reported right away.
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.
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