A resident with heart failure, anxiety, depression, and moderate cognitive impairment alleged that a man entered the room at night, touched the resident’s ankle and leg, and attempted rape. A psychiatric APRN was urgently consulted and documented differing versions of the event, ultimately concluding it was most likely a nightmare or delusion, while social services documented the allegation and interviewed two other residents about any male presence or screaming. Despite these reports, the facility did not complete a formal incident report or a thorough abuse investigation; instead, unsigned and partially unidentified staff statements were kept in informal files, and there was no comprehensive review of statements or clinical notes as required by the facility’s abuse and incident policies.
A resident with moderately impaired cognition and multiple chronic conditions had a personal electronic tablet reported missing after a hospital stay. The resident’s representative reported the missing or stolen tablet to the Administrator, and the SW was informed that the device was missing and needed replacement, but this communication was not documented in the medical record. Review of records and interviews with the DNS, Administrator, and SW showed that no investigation into the alleged misappropriation was initiated or completed, despite facility policy requiring reporting and a written social service report for alleged violations.
Failure to Investigate Resident Abuse Allegations and Resident-to-Resident Conflict A resident with schizophrenia, dementia, and anxiety disorder was documented yelling at and physically assaulting a roommate, yet the facility did not complete a thorough abuse investigation or document protection from further abuse. Another resident later reported daily verbal and physical abuse by the same roommate, including being hit and shoved, but the Administrator was unaware of the allegations and the letter was not reviewed. The report also described repeated verbal and physical altercations between two other residents with psych and mood disorders, with no thorough investigation or clear documentation of how they were separated and protected from each other.
The facility failed to thoroughly investigate a resident-to-resident sexual incident involving two cognitively impaired residents with dementia and psychiatric diagnoses. A recreation assistant observed the residents kissing in an elevator, with one resident’s hands inside the other’s pants, and reported the event to the DNS. Although the facility interviewed the witness and the involved residents, it did not obtain timely interviews or statements from other staff to determine how long the residents were unsupervised or where they had been prior to the incident, despite a policy requiring identification and interviewing of staff who might be witnesses and review of work schedules.
A resident with dementia, cognitive deficits, and Parkinson's disease with dyskinesia, who was dependent on staff for most ADLs and required two-person mechanical lift transfers, was found with an unwitnessed hematoma on the forehead while seated at the nurse’s station. No staff witnessed the incident, and only two NAs from the prior shift were interviewed, whose statements were inconclusive and based on an assumption that the resident hit their head on the bed’s headboard due to dyskinesia. The ADNS did not follow policy requiring a 72-hour look-back and broader staff interviews, did not interview the unit nurse who had interacted with the resident minutes before the injury was noted, and, after discussing with a regional RN, did not report the event to the State Agency as an injury of unknown origin based on the unverified assumption of cause.
Failure to Investigate Allegation of Resident-to-Resident Abuse: A resident with severe cognitive impairment was found with bruising around both eyes and later told the ED that another resident had hit him/her in the face. The facility’s incident report noted bruises of unknown origin and later included the abuse allegation, but no investigation was identified in the A&I report. The DON stated the allegation was not investigated because she was unaware of it; another resident with dementia, anxiety, and depression was also reviewed for abuse.
Failure to investigate resident-to-resident verbal abuse: Staff knew one resident was verbally aggressive, intimidating, and used sexually explicit profanity toward another resident, but no incident report or full investigation was completed. The targeted resident later reported ongoing intimidation and retaliation concerns, and psych notes documented increased anger, paranoia, delusions, and distress. Facility records did not identify the other resident involved, and staff stated they did not report the event because they did not view it as abusive.
A resident with epilepsy and multiple sclerosis experienced a seizure and was sent to the ED, where family members reported to hospital staff that the facility had withheld the resident’s anti-seizure medications. The former DON documented awareness of this allegation and reviewed the resident’s MARs but did not initiate a formal investigation, enter the allegation into the risk management system, or report it to the State Agency. No related grievance entry, A&I report, or state reportable event was found, and the Administrator stated she was only vaguely informed of a medication issue and was unaware it was an allegation of neglect. These omissions conflicted with the facility’s abuse prohibition policy requiring timely reporting and thorough investigation of suspected neglect.
Failure to Investigate Alleged Neglect: A resident with severe cognitive impairment, total incontinence, and dependence for care was found saturated with urine and feces after reportedly not being changed for hours. The responsible party reported the incident to nursing staff and facility leadership, but no incident report, skin assessment, or timely investigation was completed, and no report was found in the state reporting portal.
A resident with dementia and a recent cerebral infarction, who was alert and required moderate assistance, reported being inappropriately touched by staff during a shower. The allegation was relayed to the ADON, but no investigation was conducted or documented, as the reporting staff member expressed doubt about the event and requested no further questioning. The DON was unaware of the incident, and facility policy requiring prompt investigation of abuse allegations was not followed.
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