Failure to timely submit the final investigation report after a resident-on-resident altercation. One resident pushed another resident out of a chair and onto the floor and attempted to hit the resident with a chair while a third resident was nearby. The Administrator stated the State Agency had been notified of the initial incident, but the final investigation was not submitted within the required timeframe and she did not know the rule was based on real clock time rather than business hours.
Failure to report an allegation of neglect occurred when an LPN left without report, narcotic count, or cart keys after the relieving nurse called out, and no nurse covered the west wing medication cart until the next morning. Residents reported waiting all night for meds, including pain meds, and MARs showed no nurse signatures for scheduled bedtime medications. The DON stated she did not complete a formal investigation and relied only on the grievance form.
Failure to Report Abuse and Neglect Allegations: The facility did not report allegations of abuse and neglect involving two residents to the proper authorities. One resident with moderate cognitive impairment had a sexual abuse allegation involving a CNA student, and another resident with severe cognitive impairment had a roommate-related abuse incident plus an allegation that staff withheld meds and ADL care. Current leadership could not produce investigation records or evidence that the incidents were reported to the state agency or APS.
Failure to Timely Report Allegations of Abuse: The facility did not timely report allegations of abuse involving two residents with severe cognitive impairment. Staff documented one resident repeatedly touching another resident inappropriately, but the former ADON did not report the incident beyond management and did not notify the DON, Administrator, or SSA. The DON later stated the incidents should have been reported. The facility policy required reporting alleged abuse within 2 hours if abuse was involved, or within 24 hours if not involving serious bodily injury.
A resident alleged that two housekeeping employees attempted to expose themselves and made sexual comments toward her, but the facility did not remove the alleged perpetrators from resident contact while the abuse investigation was pending. Records showed both employees continued working full shifts after the allegation was reported, and the investigation file did not document increased supervision, separation measures, or a rationale for allowing continued access to residents.
Failure to report an allegation of verbal abuse involving two residents. An LPN witnessed one resident arguing and cursing at another resident after the second resident had been yelling earlier, separated them, and documented the event, but the incident was not reported to management or the SA as an abuse allegation. The Administrator later stated it should have been reported and investigated.
A resident with altered mental status developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped both wrists against a wheelchair during transfer. An RN completed an incident report and nursing note documenting the injury, assessment, and physician notification with an order for x-ray. Facility leadership later acknowledged that this event, which met their policy criteria for an allegation requiring reporting within two hours if involving abuse or serious bodily injury, was not reported to the state survey agency, contrary to the facility’s written abuse, neglect, and exploitation policy.
Facility staff failed to timely report an allegation of abuse involving a resident with moderately impaired cognition and a diagnosis including malignant neoplasm of the colon. The resident reported being shoved back into bed by staff after nearly falling, and a facility synopsis documented that she was shoved twice by two staff members while being assisted to bed. The incident date and the report date in facility records showed a five-day delay before the allegation was reported to state agencies. Staff interviewed during the survey stated they were not aware of the incident, and leadership provided no additional information about the delay, resulting in a deficiency for failure to promptly report suspected abuse.
Failure to Timely Report Allegation of Verbal Abuse: A resident with intact cognition and ADL dependence reported that a CNA was loud, rude, bossy, and disrespectful during care, making her feel scared. The resident told another CNA she wanted to speak with the ADON about the verbal abuse, but the concern was not addressed right away and the ADON did not speak with the resident about the allegation until later.
Failure to Report Resident Allegation of Sexual Abuse: A resident with severe cognitive impairment, dementia, and behavioral symptoms made a statement interpreted as a sexual abuse allegation during CNA-assisted toileting. Nursing documented the incident and notified the social worker, but the Administrator stated it was not reported to the State Survey Agency because it was viewed as the same behavior the resident had shown previously in assisted living.
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