Incomplete investigation documentation for an alleged neglect incident. A resident with severe dementia and other serious diagnoses was found on the floor with head and extremity lacerations after falling from an elevated bed during ADL care, later sustaining a femoral neck fracture and requiring surgery. The facility could not produce witness statements or a complete investigation file, and key staff involved were unavailable for interview.
Failure to Investigate Allegation of Neglect: An LPN left the medication cart without a proper handoff, narcotic count, or secure keys, and no nurse covered the west wing overnight. The DON did not complete a formal investigation and relied on the grievance form, while residents reported delayed or missed medications and pain medication requests with no nurse available.
A resident reported that his debit card was taken and $604 was withdrawn from his bank account. During the abuse investigation, the activity assistant who was suspected of involvement returned to the facility after admin staff had left and had the resident sign a statement. The admin confirmed the facility policy required staff involved or suspected of abuse to be removed until the investigation was complete to protect the resident.
Failure to Investigate Abuse and Neglect Allegations: The facility did not document or produce a thorough investigation for two residents involving alleged sexual abuse by CNA students, a roommate throwing water on a resident, and alleged withholding of meds and ADL care. Records and interviews showed no investigation reports, no related nursing/social work/MD documentation, and no state reporting documentation available from the facility.
Failure to thoroughly investigate alleged abuse incidents involving residents with dementia. A resident with severe cognitive impairment was observed in inappropriate sexual contact with another cognitively impaired resident on more than one occasion, but the facility delayed the investigation and did not interview all staff with knowledge of the events or other potentially informed staff. Another incident involving the same resident attempting sexual contact with a third resident was documented in a nurse's note but was never investigated. The DON confirmed the investigation gaps and the missed investigation.
Failure to restrict alleged perpetrators during a sexual abuse investigation. A resident alleged that two housekeeping employees made sexual comments and exposed themselves to her, but both employees were allowed to continue working their full shifts while the allegation was being investigated. The facility’s abuse prevention policy required immediate protective interventions, yet the record lacked documentation of resident separation, increased supervision, or other interim safeguards; the resident was later noted to be guarded and worried about her safety.
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and a preferred language other than English developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped her wrists on a wheelchair. Documentation noted the injury, assessment, and treatment, but the care plan was not updated. A family member reported that the resident said staff grabbed her hand and tried to force care, and this was reported to nursing and administration. Despite this allegation, the facility did not conduct a full abuse investigation per its policy: the Social Service Director did not interview the resident or other cognitively intact residents or complete a trauma assessment, and the Administrator/DON confirmed that only the involved CNA and RN were interviewed before concluding no abuse occurred.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
Facility staff did not complete a thorough investigation of an elopement incident involving a resident with dementia and severely impaired cognition. Staff observed the resident exit through a door, go down a ramp, and the resident was then assisted back inside and assessed with no injuries, while the door alarm and a functional wander prevention device were in place. However, the facility’s investigation lacked documented witness names, written statements, or interviews from staff who witnessed or were working during the incident, despite facility policy requiring that witness identities and accounts be obtained and recorded on the incident/accident report.
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