A resident with intact cognition and expressive aphasia alleged that a CNA yelled at her, called her names, took her soda, and pushed her in the chest/shoulder area during incontinence care, while she believed two staff should have been present. Nursing staff and an LPN assessed her and found no physical injuries, and the CNA reported she only held the resident at the waist to prevent a slip and that the resident sometimes "plops" into her chair. The Administrator reported interviewing some staff and several residents on the same hall, but did not obtain written statements, did not interview all staff who worked that night, and some CNAs and residents later denied being interviewed about rough or abusive care. Facility policy required obtaining witness statements from all known witnesses and thorough investigation of abuse allegations, but the limited interviews and lack of complete documentation resulted in an incomplete investigation of the resident’s abuse allegation.
A resident with severe cognitive impairment and dementia-related behavioral disturbances became frightened during care when a CNA was reportedly rough and rushed, leading the resident to strike the CNA and the CNA to allegedly hit the resident’s thigh. A CNA reported the incident to the DON and Administrator and described being criticized and told she was overreacting, while being required to retake abuse training. The DON did not report the allegation to the state, did not complete a written investigation, and did not document the incident, assessment, monitoring, or notifications in the EHR, despite facility policy requiring formal investigation steps, documentation, and appropriate notifications for suspected abuse.
A cognitively intact resident with paraplegia, seizure disorder, respiratory failure, malnutrition, MDD, antisocial personality disorder, and PTSD alleged physical abuse by a respiratory therapist. Although staff reported promptly notifying leadership and obtaining written statements, the facility’s investigation file contained only limited, unsigned statements and lacked the original witness and resident statements, as well as documentation of additional resident and staff interviews that were later identified. Despite concluding there was no evidence to support the allegation, the facility failed to maintain complete, signed documentation and supporting materials as required for a thorough abuse investigation under its own policy.
Failure to investigate resident-to-resident abuse incidents involving a cognitively impaired resident. A resident with severe cognitive impairment, dementia, anxiety, depression, and a history of aggressive behavior was documented grabbing, pushing, poking, yelling at, and invading the space of other residents. The care plan listed general redirection and monitoring interventions but lacked specific aggression-related protections, and the facility's records did not consistently identify the other residents involved. The DON and Administrator stated they did not complete investigations for some of the incidents, and staff did not assess the affected residents for injury or psychosocial harm.
A resident with cerebral palsy, severe intellectual disability, and severe cognitive impairment, who depended on staff for most ADLs and preferred to stay in the common area, was allegedly placed in his room with the door closed by a CNA so the CNA would not have to hear his vocalizations, and kept there for an extended period despite his apparent wish to leave. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted out, but the RN only mentioned the concern to the DON in passing. The DON and Administrator stated such allegations should be reported directly to them and that the alleged perpetrator should be separated from residents, yet there was no documentation that an abuse investigation was initiated or that the CNA was separated from residents, despite an abuse policy that defined abuse to include involuntary seclusion and required timely reporting and investigation.
Two cognitively impaired residents were observed by a CNA with their hands down each other’s pants at the nurses’ station, after which they were separated and a nurse documented no trauma and notified leadership. The Administrator, relying on second-hand clarification that the residents were only holding hands in a lap and noting both had dementia, decided the incident was not reportable and did not initiate a formal investigation. The DON was not fully informed of the specific allegation, Social Services did not document the event, and no comprehensive abuse investigation consistent with the facility’s abuse/neglect policy was conducted, resulting in a failure to immediately and thoroughly investigate an allegation of potential abuse.
A resident with dementia, anxiety, muscle weakness, and severe cognitive impairment was being pushed in a wheelchair while yelling out, which staff described as normal for him. An LPN at the nurses’ station heard a CNA tell the resident to “shut the fuck up” and saw the CNA’s hand move away from the resident’s face but did not intervene or separate them. Another CNA later reported that she had seen the same CNA pinch the resident’s lips closed for several seconds while again telling him to “shut the fuck up,” and that the resident was then assisted to bed. Although facility policy required immediate measures to prevent further potential abuse, including separating an employee accused of abuse from residents, the alleged abusive CNA continued working the rest of the shift and returned for the next shift before any separation occurred.
A resident reported to a CNA that a male staff member, described by race and role, had raped them and another resident during the night. The CNA informed an RN, who stated they notified the DON that morning, but the DON reported not learning of the allegation until the following day. Review of staffing schedules showed a CNA matching the general description of the alleged perpetrator had worked consecutive night shifts and continued to work and have access to residents after the allegation was first reported to staff. This conflicted with facility policy requiring immediate protective measures, such as suspension or segregation of an employee accused of abuse, upon receipt of an abuse allegation.
The facility failed to follow its abuse prevention policy after CNAs reported that a CNA admitted to slapping a resident across the face and using profanity toward him following an incident in which he allegedly reached down her sweater and grabbed her breast. The CNAs reported the allegation to an RN and the Administrator, but the accused CNA continued to work full shifts and was not separated from the alleged victim or other residents while the allegation was under investigation, contrary to facility policy requiring immediate separation or supervision of staff accused of abuse.
A resident with a history of aggressive behaviors was involved in multiple altercations with other residents, but the facility did not thoroughly investigate the incidents or update care plans to include interventions to prevent recurrence. Required interviews and documentation were incomplete, and the facility's policy for investigating and reporting abuse was not consistently followed.
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