A facility failed to timely investigate allegations that nurses were taking insulin from one resident and giving it to another when insulin syringes were reportedly unavailable. Residents and LPNs described sharing insulin pens and vials between residents, and one resident reported missing insulin on at least one occasion. The DON was notified of the concern but initially only checked supply availability rather than interviewing residents or staff about whether insulin had been borrowed or misused.
Incomplete Investigation of Resident Abuse Allegation: A resident with cerebral infarction, restless leg syndrome, major depressive disorder, and moderately impaired cognition alleged that a CNA was rough during care and spoke unkindly. The facility’s abuse investigation included only one LSW statement, with no statement from the resident or CNA, no physical assessment, no interviews of like residents, and no suspension of the CNA while the allegation was reviewed; the DON and Administrator later verified there was no further investigatory documentation.
Accused CNA Not Removed Pending Abuse Investigation: A resident with intact cognition and total toileting assistance reported that a CNA touched his genitals during a dark room check and change, and also raised concerns about possible photos of his genitals being shared outside the facility. The investigation did not document that the accused CNA was suspended or removed from the schedule, and the CNA was allowed to return to work on another hall while the abuse allegation was being reviewed, despite facility policy requiring immediate removal of an accused or suspected staff member.
Failure to investigate and report an allegation of misappropriation involving a resident who reported missing money. The grievance form had no documented actions or resolution, the SRI log did not show the allegation was reported, and the LSW confirmed he did not notify the Administrator or state agency despite the facility policy requiring investigation and reporting.
Incomplete Investigation of Abuse Allegations: The facility did not thoroughly investigate complaints about an LPN’s rude and mean behavior toward residents. Interviews and record review showed that multiple residents, a family member, and staff reported concerns, but the investigation did not include all residents, the accused LPN, or all relevant staff witnesses as required by policy. Residents involved had varying cognitive status, including intact cognition and moderate impairment.
Failure to initiate an abuse investigation and remove the alleged perpetrator: A resident reported that a CNA cursed at her and made her cry, and she became teary eyed and stressed during interview. The DON was notified, but an SRI was not opened, the CNA was not suspended, and the CNA continued working on the resident’s unit while the resident’s allegation remained uninvestigated.
A facility failed to timely investigate an allegation of misappropriation involving a resident’s missing wallet, which contained a credit card and driver’s license. The resident’s wife reported the wallet missing to CNA and LPN staff, but management was not aware until the surveyor raised the concern. The Administrator did not initiate an SRI right away and had not completed a full investigation when surveyed, despite the facility policy requiring immediate communication and investigation of alleged misappropriation.
Failure to thoroughly investigate an allegation of staff-to-resident abuse. A resident with multiple chronic conditions and cognitive impairment reported that a Dietary Aide threw a pan at her, but the Administrator did not personally investigate and relied on the DM to review the incident. No witness statements or interview documentation were available, staff accounts were conflicting, and the resident said she was never interviewed after reporting the incident and felt afraid of the aide.
Incomplete Investigation of Alleged Verbal Abuse: A cognitively intact resident who required extensive assistance reported that a CNA made demeaning comments when she asked to use the toilet and accused her of faking diarrhea. The investigation included a statement from the accused CNA but did not obtain a statement from the other CNA identified as present, and the QARN and DON confirmed the investigation was incomplete; a separate alleged misappropriation case was also missing key investigative details.
The facility failed to complete a timely abuse investigation assessment for a resident who was unable to communicate after an allegation that a CNA pinched, slapped, and used an inappropriate name during a transfer. Although the incident was reported and staff interviewed, no timely skin or injury assessment was documented for the affected resident, who had severe cognitive impairment and multiple diagnoses including dementia, Alzheimer’s disease, and behavioral disturbance. The Administrator confirmed the assessment was not completed when the allegation was reported, despite the resident’s inability to communicate and the facility policy requiring a thorough investigation.
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