Failure to thoroughly investigate an abuse allegation and an injury of unknown origin. A resident with impaired cognition and total dependence on staff alleged sexual abuse during care, but there was no nurse assessment at the time of the allegation and key aides and an LPN were not interviewed. Another resident on hospice with impaired cognition and dependence for mobility developed right ankle pain and x-ray findings of healing tibia/fibula fractures, but the investigation did not include staff familiar with the resident or review prior records to determine the source of the injury.
Incomplete Investigation of Alleged SSN Misappropriation A CNA was arrested after police came to the facility and also reported an allegation that the CNA was stealing residents’ SSNs. The facility did not interview staff about unauthorized access to resident information, did not notify all POAs/guardians of the possible compromise, did not tell interviewed residents about the allegation, and did not audit staff access to personal information. The DON and Administrator confirmed the investigation documentation was incomplete and that no staff interviews or POA notifications were done.
Failure to Investigate Alleged Staff-to-Resident Abuse: A terminally ill resident with severe cognitive impairment was unresponsive when an RN attempted to give crushed meds mixed with applesauce. Hospice staff warned the RN not to continue, but the RN allegedly forced the resident’s mouth open and placed the mixture inside despite the family’s اعتراض. The family and hospice nurse reported the event as abusive, but facility leadership did not treat it as abuse or promptly report and investigate it.
Incomplete Investigation of Missing Resident Belongings: A resident with multiple chronic conditions and intact cognition had family report that his wallet, cards, checks, phone, watch, jewelry, and clothing were missing. Facility records said the items were in the room when he went to the hospital, but the investigation was deemed unsubstantiated because the items were not found and the cards/checks were not used. The DON/Administrator could not verify how the conclusion was reached or locate the resident’s inventory log, and the Housekeeping Supervisor later found the belongings in a locked closet after staff had already searched elsewhere.
Incomplete Investigation of Injuries of Unknown Origin: The facility did not complete thorough investigations for two residents with injuries of unknown origin. One resident with dementia, osteoporosis, and multiple fractures was found in severe pain with a new femur fracture, but the SRI lacked statements from all relevant staff and did not include staff education or like-resident review. Another resident with Alzheimer’s disease and vascular dementia had an unexplained bruise, but the investigation did not identify the reporting staff or hall, included only some staff statements, and lacked evidence of abuse training or a resident assessment.
Failure to thoroughly investigate an alleged abuse incident involving a resident with mild cognitive impairment and a guardian. The resident reported that a CNA was rough during care and caused bruising, but staff only completed a skin assessment that found no bruising and did not complete a full investigation. The DON, UM, LVN, and Administrator acknowledged the limited follow-up, and the record contained no documentation of a complete abuse investigation despite facility policy requiring interviews with the resident, accused staff, witnesses, and other employees.
Incomplete investigation documentation for abuse, neglect, and misappropriation allegations. The facility’s files for three SRI cases did not contain the resident interviews, staff interviews, witness statements, or head-to-toe assessments described in the investigation summaries. One file was mostly care plan information, and some witness statements were only sent after survey exit. The Administrator acknowledged the missing documentation and the delay in providing the records.
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.
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