Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: The facility failed to report an allegation of abuse for a resident with chronic pain syndrome, rheumatoid arthritis, major depressive disorder, and moderate cognitive impairment within the required 2-hour timeframe. The DON stated the ADON completed the investigation but did not timely notify OSDH, and there was no documentation that APS or the Nurse Aide Registry was notified at the time of the initial report.
Delayed Reporting of Abuse Allegation: A resident with moderate cognitive impairment and a history of bone cancer reported that a CNA was rough during incontinence care. The hospice nurse informed facility leadership, but the allegation was not reported to the state survey agency within the required 2-hour timeframe; the DON and Administrator acknowledged the delay.
Failure to Timely Report Suspected Abuse: A CNA did not immediately report a suspected abuse allegation involving a resident with Alzheimer’s disease, anxiety, and major depressive disorder. Instead of notifying an on-duty supervisor or the Abuse Coordinator, the CNA texted the off-duty ADON, and the allegation was not reported to the SSA within the required timeframe. Staff interviews confirmed the Abuse Coordinator was not notified immediately, and the DON and Administrator acknowledged the delay.
Failure to Report Allegation of Physical Abuse: A resident with severe cognitive impairment and Alzheimer's dementia was involved in an altercation with another resident after trying to take the other resident's food tray. The resident grabbed and clawed the other resident's arm, causing a skin tear with moderate bleeding, and both residents attempted to hit each other before staff separated them. The DON later stated the incident had not been known but should have been reported.
Failure to Report and Investigate Suspected Employee Drug Use: RN found a purse in an employee restroom containing suspected illegal drugs and drug paraphernalia, then questioned two CNAs, monitored them for impairment, and allowed them to keep working. The DON later identified the purse as belonging to one CNA, returned it, and transported the CNA home without contacting police, requesting a drug screen, or reporting the incident at the time. Staff later stated the facility did not have a criminal activity policy and that suspected criminal activity should have been reported and investigated.
Failure to timely report an elopement and an abuse allegation. One resident left the facility and was found at an apartment nearby, but the incident was not reported to the OSDH within 24 hours as required. In a separate event, a resident alleged that an LPN pushed and yelled at them, but the allegation was not reported to the OSDH and law enforcement within 2 hours.
Failure to Immediately Report Suspected Abuse: A CNA witnessed another CNA allegedly scream at a resident and push the resident onto the bed, but did not immediately report the suspected abuse through the charge nurse chain of command. The resident had severe cognitive impairment, and interviews showed conflicting accounts about whether the allegation was reported to an LPN. Management learned of the concern the next day.
Failure to timely report abuse allegations: The facility did not notify OSDH and law enforcement within 2 hours after abuse allegations became known for two residents. One resident reported sexual abuse to staff, and another resident was thrown to the ground by another resident; in both cases, the reports were sent later than required and law enforcement was contacted after the delay.
Failure to Timely Report and Finalize Abuse Allegations: The facility did not report one resident’s allegation of attempted rape to the OSDH within 2 hours and did not submit a final report within 5 days for another resident’s allegation of inappropriate touching. One resident had dementia, depression, and psychosis, and the other had severe cognitive impairment with a BIMS score of 6. Staff said the allegations were reported internally, but the DON and administrator acknowledged the OSDH reporting requirements were not met.
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