A cognitively intact resident with multiple medical conditions had an abuse allegation reported by an outside complainant, who informed the Social Services Director that someone was allegedly trying to suffocate the resident with a pillow and that the resident was being forced to drink an unknown green substance. Although facility policy and staff statements indicated that any abuse allegation must be reported to the SA, APS, Ombudsman, and the Administrator within required time frames and investigated through interviews and documentation review, the Social Services Director did not notify any agencies or the Administrator and did not initiate an investigation, relying instead on the absence of abuse documentation in the medical record. The DON, an LPN, and the Administrator all reported that they were unaware of any allegation or investigation for this resident, and review of the written policy confirmed that the facility failed to follow its own procedures for reporting and investigating the abuse allegation.
A minor with TBI, ADHD, anxiety, and depression, whose healthcare decisions were made by a legal guardian and who required supervision with all decision-making, developed a close relationship with an adult resident with serious mental illness. Staff had prior concerns and had warned the adult that the other resident was a minor, and the guardian had been notified that the minor was to remain in public areas. One evening, an LPN entered another resident’s room and observed the adult on her knees in front of the minor, whose pants were down, in the bathroom; the residents were separated and the DON was notified. Both residents later acknowledged a sexual encounter, describing it as consensual and initiated by the minor, and the police classified the event as sexual assault of a minor and completed statutory rape. The facility’s 5-day investigation did not identify the younger resident as a minor in reports to the State Agency, concluded the event was between consenting individuals, omitted a statement from the nurse who discovered the incident, did not interview the room’s assigned resident or other residents about what they saw or heard, did not document protective interventions on the date of the incident, and did not report to child protective authorities at the time, despite policy requirements for prompt recognition, reporting, and thorough investigation of abuse.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
A resident with multiple neurologic and functional impairments, but intact cognition, reported feeling neglected after being left in a wet brief and requested that law enforcement be called. The resident’s spouse alleged that an RN and CNA provided rough care during a brief change, ignored the resident after he asked them to stop, and left his bed remote out of reach, and she filed police reports for abuse and neglect on two occasions. The ED documented the concern, briefly interviewed the resident and spouse, concluded that care had been provided, and decided not to report the later allegation to the State Survey Agency, APS, or other required entities because the resident’s account differed from his wife’s, despite facility policy requiring that all alleged violations of abuse or neglect be reported within specified timeframes regardless of how the allegation is characterized.
The facility failed to implement its abuse, neglect, and misappropriation policy by not maintaining investigation reports and contemporaneous clinical documentation for multiple allegations involving several residents. State records showed reports of lost personal property, financial misappropriation, resident‑to‑resident altercations, and alleged inappropriate sexual contact, often involving residents with dementia, traumatic brain injury, psychiatric disorders, and significant physical impairments. In numerous cases, the facility could not produce five‑day investigation reports, nursing progress notes, care plans, MDS assessments, or even basic identifying records for the timeframes of the incidents, and in some instances denied that an involved resident had ever lived there. Leadership acknowledged that records and investigation documents from before a change of ownership were not available, despite a stated retention expectation of ten years, resulting in noncompliance with the written abuse prevention and documentation policy.
A resident with dementia and significant cognitive impairment was observed by a CNA being subjected to aggressive behavior by a visiting friend during feeding, including flicking the resident’s nose and yelling at the CNA when redirected. The CNA reported the incident to an RN, who in turn reported it to the DON, and the resident’s daughter requested that it be reported to the case worker. The DON and Administrator/Abuse Coordinator acknowledged awareness of the allegation but, after interviewing the resident, decided not to treat it as abuse and did not report it to outside agencies or document it as an abuse allegation or grievance. Review of logs and records showed no documentation of required reporting or interventions toward the visitor, despite facility policy mandating immediate removal of the visitor, reporting to law enforcement and state/federal agencies, and a comprehensive investigation for any visitor-related abuse allegation.
The facility failed to implement its abuse policy after an incident in which a resident with a history of aggressive behaviors created a cardboard gun, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not quiet down. Staff, including a CNA and an LPN, witnessed the event, described it as resident-to-resident emotional abuse, and reported it verbally to a unit manager, but there was no documentation of the incident in either resident’s clinical record, no incident report, and no evidence of an investigation or required notifications. The DON, who is responsible for abuse coordination and reporting, was unaware of the event, despite facility policy requiring immediate reporting, documentation, resident examination, and notification of state agencies, the physician, and the resident representative for any suspected or alleged abuse.
A resident with vascular dementia and moderate cognitive impairment, who transitioned from insurance coverage to private pay, had large sums of money allegedly drained from personal accounts while residing in the facility. The resident’s private fiduciary reported suspected fraud to the facility and police, requested records, and stated that the resident’s financial mail and retirement statements were kept unsecured in a nightstand accessible to anyone entering the room. Although the Business Manager notified the then-administrator of the fiduciary’s allegations and request that facility staff be investigated, the current administrator later acknowledged that no investigation was conducted, contrary to the facility’s abuse policy requiring prompt, thorough investigation of all allegations of misappropriation and exploitation.
A resident with a history of sexually inappropriate behavior and no cognitive impairment was reported by staff to have placed his hands down the pants of another resident with severe cognitive impairment while they were kissing, and to have previously made sexually explicit comments in common areas. The alleged victim’s record contained no documentation of the incident, and the facility did not report the allegation to the State Agency, Ombudsman, or law enforcement. The DON and Administrator reviewed video footage, concluded the interaction was behavioral rather than abuse, did not identify the involved female resident, allowed the footage to be auto-deleted, and did not conduct or document a thorough investigation as required by the facility’s abuse reporting and investigation policy.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in a bed with one resident’s shirt off and the other hovering over them. Staff acknowledged that both residents were not alert and oriented and could not consent, and one nurse had previously documented kissing behavior between them and recommended separating or moving them. Despite this, the facility did not revise either resident’s care plan to address the sexual behaviors, did not document the incident in progress notes beyond a single behavior entry, did not change room assignments even though their rooms were directly across from each other, and did not submit a facility-reported incident to the state agency, contrary to its abuse, neglect, and exploitation prevention policy requiring investigation, reporting, and protection of residents during investigations.
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