A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a shared landline phone and threatened to kill her and her sister, with the sister confirming she overheard these threats. The resident told a CNA and was moved to another room, but later reported that the roommate continued to intimidate her by making finger gun gestures when passing her door. The SSD was notified by a CNA of verbal threats and filed an APS report, but did not clearly ensure that the DON was informed or that staff were interviewed about ongoing gestures. The DON believed the incident involved only a phone altercation with the sister, concluded there was no resident abuse, and therefore did not initiate an investigation or report the allegation to the state agency, resulting in a failure to document, report, and thoroughly investigate the verbal abuse allegation.
The facility failed to complete and maintain required written statements during an abuse investigation after a resident with Down Syndrome witnessed a verbal argument between a QMA and a CNA. The investigation file contained an incident report and a written statement from the QMA, but no written statement from the CNA, despite the CNA reporting that she had submitted one. The ED stated the CNA’s input was obtained verbally and over the phone and was not documented as a written, signed, and dated statement as required by the facility’s Abuse Prevention Program policy and state regulation.
The facility failed to thoroughly investigate multiple resident-to-resident abuse incidents involving one cognitively impaired resident who repeatedly pushed other residents, causing falls and, in one case, injury requiring ER transfer. Several residents with dementia and mobility or cognitive impairments reported or were documented as being pushed, resulting in loss of balance and falls. Facility documentation focused on falls and environmental or behavioral interventions, but the investigation files provided by the Administrator lacked abuse investigations for these altercations, even though the Administrator acknowledged being informed of at least one pushing incident.
A resident with severe cognitive impairment and multiple comorbidities had a care plan including video monitoring and a STOP sign at her doorway. A male resident entered her room on more than one occasion, including an incident captured on family-installed cameras where he approached her bed while she slept, opened his robe, and ultimately sat on her chest and shoulder, causing her to cry out in pain before staff removed him. The resident’s representative reported this allegation to the Administrator by email, but the facility did not complete a thorough abuse investigation as required by its policy to investigate all alleged violations reported by residents or relatives.
A resident with severe cognitive impairment, high fall risk, and wandering behavior was observed by his spouse and later by surveyors with a swollen, darkly bruised eye, while staff reported they did not know the cause and had no immediate plans for further testing. Documentation noted the puffed, dark eye but lacked any assessment of VS, neuro status, or the orbital area, and there was no evidence of timely notification of the physician, leadership, or the spouse. The DON learned of the injury days later, was unsure who discovered it, and although a risk management entry was made, no prompt interviews or investigation were completed, contrary to the facility’s policy for unexplained injuries.
A facility failed to thoroughly investigate an abuse allegation after a resident with severe cognitive impairment and multiple disabilities was reported to have been inappropriately touched by staff. The investigation was limited to a physical assessment and did not include interviews with other staff or residents, nor was the incident documented in the resident's record or communicated to the family.
Two residents with cognitive impairments were involved in separate incidents of alleged sexual abuse by another resident with intellectual disabilities. Staff observed inappropriate situations, including exposure and possible sexual contact, but did not follow proper investigative protocols or protective interventions. Documentation was incomplete, communication among staff and leadership was inconsistent, and the facility failed to report the incidents as sexual abuse to the state. Family members learned of the events through anonymous calls, raising concerns about transparency and adherence to abuse prevention policies.
A facility failed to properly investigate and report an allegation of staff-to-resident abuse involving a resident with dementia. The incident, witnessed by a dietary manager, was not thoroughly documented or reported to the state as required by facility policy. The administrator did not collect written statements from all involved staff and did not separate the alleged perpetrator from resident contact during the investigation.
A resident with significant medical needs reported being yelled at by CNAs, and the facility failed to conduct a thorough abuse investigation and did not implement immediate interventions to prevent potential abuse during the investigation. Documentation was incomplete, staff interviews were missing or improperly dated, and the resident and her representative described feeling intimidated and upset by staff comments regarding incontinence. The facility did not follow its own policy for investigating abuse allegations.
The facility did not thoroughly investigate or ensure protection following multiple allegations of sexual abuse involving a resident with severe cognitive impairment and two other residents with moderate cognitive impairment. Despite reports and witness accounts of inappropriate touching during smoke breaks, the facility failed to interview all involved parties or document the reasons for safety interventions, resulting in repeated incidents and ongoing distress for the affected residents.
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