The facility failed to report an allegation of abuse to the State Agency after a CMA observed an interaction between two cognitively impaired residents, including one resident being found in another resident’s room with his pants down. The CMA notified an LN, who contacted administrative staff, and an internal investigation was conducted, including interviews with both residents and review of video showing one resident in the other’s room for over a minute before staff intervened. Despite being informed of an incident described as inappropriate touching and having a policy requiring all alleged abuse to be reported, facility leadership, in consultation with corporate, decided not to report the allegation, concluding they could not determine willful intent and that the residents could make decisions about the interaction.
A resident with a DPOA frequently present during care developed significant bruising on the right leg and later bright red vaginal bleeding and labial injuries, which were repeatedly observed and reported by CNAs to RNs/LPNs over the course of a shift. Nursing staff accepted the DPOA’s explanations, attributed findings to therapy, wheelchair use, itching, or yeast infection, did not promptly assess or document all injuries, and failed to recognize them as potential physical and sexual abuse or injuries of unknown origin requiring immediate reporting. Despite additional observations of dried blood, vaginal lacerations, extensive bruising resembling a handprint, abdominal bruising, petechiae, and the resident’s anxious statements, administrative staff, LE, and the SA were not notified within required timeframes, and the resident remained alone in the room with the alleged perpetrator for many hours before suspected abuse was finally reported.
A resident with dementia, Alzheimer's disease, and documented aggressive behaviors was involved in a resident-to-resident altercation in which she grabbed another resident and required redirection and removal from the area. Nursing documentation described the physical altercation and subsequent 1:1 interaction for calming, but staff did not recognize or treat the event as potential abuse. The incident was not reported to administration or the State Survey Agency, and no investigation, incident report, or witness statements were initiated, despite a facility abuse policy requiring immediate reporting and investigation of suspected abuse, including abuse by other residents.
Failure to Report Resident-to-Resident Abuse Allegation: A resident with dementia, Alzheimer’s disease, and significant cognitive impairment pinched another resident, who also had severe cognitive impairment. The event was documented in the chart, but the incident was not immediately reported to the Administrator or the SA, and the investigation record showed the residents’ representatives and key facility leaders were not notified. The injured resident had no visible bruising or redness on follow-up, but the record lacked further documentation of psychosocial follow-up related to the event.
The facility failed to submit completed abuse/neglect investigations to the State Agency (SA) within the required five working days for two residents. In one case, a resident’s representative reported that the resident used the call light for urgent medical assistance during the night, staff did not respond in a timely manner, and the resident remained unattended while in acute physical distress. In another case, a resident with a clogged catheter was reportedly pushed into the lobby for discharge so a new admission could use the room, and the resident was instead sent to the hospital at the representative’s request. Although both allegations were reported to the SA, the completed investigations were not submitted on time due to miscommunication and assumptions between administrative staff, and the facility’s abuse policy did not specify the required timeframe for submission to the SA.
The facility failed to submit multiple completed abuse, neglect, exploitation, and misappropriation investigation reports to the State Agency within the required five working days after the incidents were reported. Several investigations were only provided much later during an on-site survey or by e-mail, and at least one investigation was neither submitted within the required timeframe nor available to surveyors. Administrative leadership acknowledged that some investigations were incomplete, contributing to delays, despite facility policy requiring the administrator to thoroughly investigate allegations, complete final reports, and submit them promptly to the appropriate agencies without withholding any reports.
Staff failed to promptly report observed and suspected abuse, including aggressive and verbally abusive behavior by a CNA toward multiple residents. Several staff members witnessed or were informed of inappropriate comments, harsh treatment, and attempts to physically force a resident, but did not immediately notify administration as required by policy. The affected residents included individuals with limited alertness, some of whom showed signs of distress.
A resident with severe cognitive impairment and behavioral issues was subjected to staff-to-resident abuse by an LPN, who responded to the resident's aggression with threats, physical restraint, and inappropriate handling. The incident was witnessed by a CNA, but was not reported to administration until the following day, violating facility policy requiring immediate reporting of suspected abuse and resulting in immediate jeopardy.
A resident entered another resident's room and attempted to strike both the resident and his wife, resulting in a red mark and later bruising on the resident's face. Staff and administrative personnel were notified, and EMS and law enforcement responded, but the required report to the State Agency was not made within the mandated timeframe, in violation of facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
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