Failure to Prevent Retaliation Against Staff: The facility failed to prohibit and prevent retaliation after staff attempted to speak with surveyors and report concerns. Although the handbook and posted notice included anti-retaliation language, five terminated employees had personnel files that did not support the reasons given for termination, and the NHA cited vague reasons such as professionalism, job abandonment, refusal to complete an admission, aggression, and alleged inciting of a verbal riot. Confidential interviews described management questioning staff about speaking with the surveyor, threats of immediate termination for calling the state, and a climate of fear related to complaints about staffing and resident care.
A resident with COPD and CKD, who was cognitively intact, reported an alleged sexual relationship with a nurse aide. Facility policy required any employee accused of abuse to be placed on leave with no resident contact, but after the allegation was reported and the aide was suspended, he still entered the resident's room. Staff and leadership later confirmed this contact occurred after the suspension and was inconsistent with policy.
A resident with a BIMS of 15 reported that a male RN gave her cough syrup without an order after she had a cough. Facility records showed no active or discontinued order for the medication, and the incident was later identified as possible medication misappropriation or medical neglect. The DON did not begin investigating immediately, the nurse continued working for several shifts after the allegation was reported, and the investigation was not completed until days later.
Facility records and staff interviews showed that required new hire screening was not followed for abuse prevention. An RN Unit Manager was hired before the criminal background check was completed, an LPN had no license verification in the file, and a nurse aide was hired before registry verification was completed. The NHA stated the facility allowed FBI background checks to be completed up to 90 days after hire and acknowledged the screening process was not followed as written.
Failure to Verify Licenses and References Before Hire: Facility review found that three of five newly hired employees, including two LPNs and the Administrator, started work before required reference checks and license verification were documented. The facility policy required screening potential hires through the appropriate licensing boards and registries, but there was no evidence that those checks were completed before the employees began working among residents. The Administrator confirmed the missing documentation during interview.
Failure to investigate resident-to-resident sexual abuse allegation: Two residents with dementia, one moderately cognitively impaired and the other severely cognitively impaired, were involved in an incident where a nurse aide observed one resident with his hands inside the other resident’s brief in the genital area. Staff did not obtain timely written statements, did not document resident assessments or investigative findings at the time, and there was no documented evidence that physicians or resident representatives were notified or that protective interventions were implemented until the resident was later moved to another unit.
A facility failed to fully investigate and protect a female resident after repeated allegations of resident-to-resident sexual abuse by a male resident. The resident, who had moderate cognitive impairment, reported that the male resident entered her room and touched her inappropriately, but the investigation relied on limited interviews, did not include the roommate who was present during the first incident, and was closed as unsubstantiated due to lack of witnesses and a denial by the accused resident. A later allegation was handled similarly, with only limited staff interviews and no documented corroborating resident interviews.
The facility failed to ensure required abuse prevention training was completed in a timely manner for one newly hired LPN. Facility policy required abuse training during orientation, but the LPN began working with residents before completing the training, which was not finished until six days after starting.
The facility failed to thoroughly investigate and report a resident-to-resident physical abuse allegation involving two residents after staff found one resident on the floor and heard statements indicating a physical altercation. The DON was notified, but the facility did not complete an investigation, obtain witness statements, or notify law enforcement or the state agency. The facility also failed to follow abuse prevention screening requirements for newly hired staff, including missing registry verification, incomplete employment history, delayed abuse training, and late criminal background verification.
The facility failed to ensure that all staff received required abuse prevention and reporting training after a confirmed abuse incident involving a resident with dementia, bipolar disorder, anxiety disorder, and impulse disorder who was resistant to care and appeared anxious when approached. Following an event in which a nurse aide verbally abused and struck this resident during incontinence care, the facility initiated whole-house education on abuse and staff reporting responsibilities. Review of in-service records and interviews with the NHA and DON showed that one activities aide hired before the incident, and still working with residents, had no documented completion of these abuse-related trainings, contrary to facility policy requiring ongoing abuse education for all staff.
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