Failure to Report Allegations of Abuse, Neglect, and Misappropriation: The facility did not timely report allegations involving a resident’s missing money, another resident’s complaint that an LPN missed ordered nebulizer tx and was verbally abusive, and a third resident’s report that he was left soiled for an extended period. Records and interviews showed the allegations were made to staff and leadership, but no timely investigation reports were found in the state portal for the residents involved.
Failure to investigate a resident-to-resident abuse allegation. Two residents with severe cognitive impairment were involved in a physical altercation after one resident was banging on a door and the other confronted him; staff described pushing, kicking, punching, and a wooden back scratcher being present, with one resident sustaining facial injuries and being sent to the ER. The ADM stated she initially thought it was only a verbal exchange and did not realize physical abuse had occurred until shown the RN note, and she acknowledged the incident should have been investigated and reported within the required timeframe.
Incomplete Investigation of Alleged Abuse: The facility did not have evidence that an allegation that a resident was pinched by staff was thoroughly investigated. The resident had moderate cognitive impairment and bruising to the L forearm. The provider investigation report lacked an identified perpetrator, documentation of who was contacted, and witness statements. The ADM and DON interviewed the resident and completed safe surveys, but no written staff statements were available and the investigation documentation was incomplete.
Failure to investigate allegation of neglect and skin breakdown: A resident admitted for rehab with a left knee wound, UTI, and dependence for all ADLs was later sent to the hospital for lethargy. The family reported staff often did not provide repositioning or incontinent care, and hospital staff later told the family the resident had ulcers to the buttocks and neck that may have contributed to systemic infection. The DON and Administrator decided the allegation lacked merit based on an enema care note and did not report it as ANE.
Incomplete Abuse and Injury Investigations: The facility’s abuse/neglect investigations for multiple residents were documented without witness statements or interview summaries. The reports involved resident-to-resident altercations, alleged abuse, and injuries of unknown origin, including a resident with a fractured toe, a nonverbal resident with finger swelling and bruising, and several incidents where residents were reported to have hit, scratched, kicked, or thrown coffee at each other. The Administrator signed the reports as unfounded, but the investigation files did not contain the supporting staff interviews described in the state form instructions.
Failure to Investigate Resident-to-Resident Abuse Allegation: A resident admitted to striking his roommate, but the facility did not complete a thorough abuse investigation. The DON and AIT stated they treated it as a grievance and did not report it as abuse, and the SW was unaware of the incident. Records showed one resident had severe dementia and behavioral concerns, while the other had intact cognition; the facility policy required immediate investigation of suspected abuse and resident-to-resident altercations.
The facility failed to fully document an abuse investigation involving a resident-to-resident verbal altercation. A resident with cerebrovascular disease, DM2, anxiety, and dysthymic disorder was placed on 1:1 supervision as the aggressor, but the hourly monitoring record was missing for one day. The facility also could not produce proof that staff received the resident-to-resident abuse in-service, and staff and leadership were unable to verify attendance or locate the missing documentation.
Failure to Investigate and Report Unwitnessed Injuries: The facility did not thoroughly investigate or timely report two unwitnessed injury events involving cognitively impaired residents. One resident with dementia had bruising and a laceration near the eye, and staff later stated the event was unwitnessed and should have been reported to the State Survey Agency. Another resident with Alzheimer’s disease and severe cognitive impairment was found on the floor with facial and wrist lacerations; staff and the DON acknowledged the unwitnessed fall required investigation and reporting, but it was not reported to the State Survey Agency.
Failure to Thoroughly Investigate Alleged Staff Mistreatment: A resident with significant cognitive impairment and multiple chronic conditions requested PRN pain medication and later became involved in a profanity-filled exchange with an LPN at the nurse’s station. A CNA reported hearing the resident and the LPN cuss at each other, while the resident said he was in pain and did not receive the medication. The DON and Administrator reviewed the allegation but did not report it to HHSC, despite facility policy requiring all allegations of abuse or mistreatment to be investigated and reported.
A resident with dementia, severe cognitive impairment, partial blindness, and high elopement risk was found outside after going out a room window without staff awareness. Staff later documented that the resident exited through the window, with the screen pushed out and her wheelchair left in front of it. The ADM stated the incident was not reported because the resident did not leave the building, and the facility did not thoroughly investigate the allegation as required by policy.
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