The facility failed to complete a thorough investigation after a resident with multiple comorbidities and intact cognition was found with neck injuries that were later revealed to be self-inflicted in a suicide attempt using a razor. Although the resident expressed ongoing suicidal ideation and items such as a razor, letter opener, and pocket knife were removed from the room, the required five-day investigation report was incomplete, lacking resident and staff interviews, skin assessment documentation, a detailed description of events, and investigative conclusions, contrary to the facility’s abuse/neglect policy and the expectations described by the ADON and Administrator.
A cognitively intact resident with multiple medical conditions was the subject of an abuse allegation reported by a complainant, who stated someone was trying to smother the resident with a pillow and that the resident was being forced to drink an unknown green substance. The Social Services Director, who along with the DON is designated to receive and investigate abuse complaints, acknowledged receiving the complainant’s call but did not initiate an investigation because there was no documentation of abuse in the medical record and instead assured the complainant that no abuse had occurred. The DON, Administrator, and an LPN all reported they were unaware of any abuse allegation or investigation for this resident. Review of the State Agency database confirmed there was no facility self-report or 5-day investigation report, despite facility policy requiring prompt reporting and investigation of all suspected abuse incidents.
The facility failed to recognize and thoroughly investigate a sexual encounter between a minor and an adult resident as potential sexual abuse, instead documenting it as a consensual event between cognitively intact individuals. An LPN reported finding the two in a bathroom during the act and notified a supervisor, but the facility’s internal investigation omitted a written statement from this nurse, did not interview the roommate or other residents (including other minors), and relied on interviews with staff who had not worked the shift when the incident occurred. Clinical records showed only vague references to a “reported event” and did not document timely protective interventions on the date of the incident, nor any prior supervision or measures to limit the pair’s unsupervised contact despite staff awareness that one was a minor. The facility did not identify the younger resident as a minor in reports to the State Agency, did not report the incident to DCS, and did not follow its abuse policy requiring prompt, comprehensive investigation, resident protection, and mandated external reporting.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
The facility failed to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation involving several residents with complex medical and psychiatric conditions. In numerous cases of alleged resident-to-resident altercations, loss or misuse of funds, and inappropriate sexual contact, the facility could not produce five-day investigation reports, contemporaneous nursing notes, care plans, or even basic clinical records for the residents involved. Facility leadership acknowledged that records and investigation reports from before a change of ownership were unavailable, despite policy and record-retention expectations, resulting in an inability to verify that required abuse investigations were completed in accordance with the facility’s abuse prevention policy.
A resident with multiple comorbidities and moderate to severe cognitive impairment was observed by a CNA being flicked on the nose in an aggressive manner by a visiting friend while being assisted with feeding. The CNA intervened, and the visitor became confrontational and yelled at the CNA, who then reported the incident to an RN. The RN documented the event and notified the resident’s daughter, but no abuse allegation was reported, and no formal abuse investigation was documented in the record or grievance log. The DON and Administrator/Abuse Coordinator acknowledged awareness of the incident and decided it did not meet criteria for abuse or neglect, despite facility policy requiring thorough investigation of all abuse allegations, including interviews with the reporter, resident, witnesses, and alleged perpetrator and review of the medical record and circumstances.
The facility failed to submit a required 5‑day abuse investigation report to the State Survey Agency after an incident in which a resident with depression, schizophrenia, quadriplegia, and moderately impaired cognition became physically and verbally aggressive, attempted to run into staff and others with an electric wheelchair, kicked a CNA, and was then transferred to a recliner while the CNA yelled loudly. Although the event was documented on an internal suspected abuse investigation form and facility leadership described a process that includes immediate investigation and submission of a detailed report within 5 working days, surveyors found no evidence in the clinical record or facility files that the mandated 5‑day investigation report was completed or sent, and the administrator confirmed that no such report existed.
The facility failed to maintain documentation showing that an allegation of financial misappropriation between two cognitively intact residents was thoroughly investigated. One resident with depression, COPD, anemia, and weakness reported that a younger resident, whom she had befriended, used her debit card and cash without permission, leading to distress, increased anxiety, and a desire to leave the facility. Staff interviews confirmed that the situation was viewed as financial abuse or exploitation and that outside agencies and police were contacted, but the incident follow-up report omitted the residents’ identities and lacked staff or resident interview statements. When surveyors requested the self-report and investigation records for the period in question, the administrator could not locate any reportable event or complete investigative documentation, resulting in a deficiency for failure to maintain records of a thorough investigation.
The facility failed to investigate and document an alleged resident-to-resident abuse incident in which a cognitively intact resident with a history of verbal aggression and threatening behaviors entered the room of a severely cognitively impaired resident while holding a cardboard gun, covered his face with a bandana, and threatened to shoot the other resident if he did not quiet down. Staff, including a CNA and an LPN, reported that they witnessed the event, considered it abuse, and informed a unit manager, but there was no documentation of the incident in either resident’s clinical record, no evidence of a self-report, grievance, or investigation, and the DON reported having no knowledge of the event. This inaction conflicted with the facility’s Abuse Guidelines policy, which required immediate reporting, documentation, examination, and investigation of all suspected abuse, including resident-to-resident abuse.
The facility failed to thoroughly investigate an allegation that a cognitively intact resident with a history of sexually inappropriate behavior placed his hands down the pants of a severely cognitively impaired resident and engaged in kissing. Although the NP documented the staff report and the DON and Administrator later stated that video footage showed the residents holding hands and one resident’s hand on the other’s thigh, there was no incident documentation in the alleged victim’s record, no clear identification of the reporter or the involved female resident, and no evidence of a comprehensive investigation as required by facility policy. The DON characterized the event as a behavior rather than abuse, did not report it to the SA, and indicated an investigation was unnecessary because it occurred on a behavior unit, contrary to the written abuse reporting and investigation procedures.
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