Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
A resident reported that a GNA threatened to slap them after pressuring them to go to bed, and later clearly identified a specific GNA as the alleged perpetrator when that staff member entered the room. The ADON and an RN began an investigation and confirmed the resident’s identification of the GNA, and the Ombudsman also received the same allegation and identification from the resident. Despite this, and despite time records showing the identified GNA was working multiple evening shifts during the period in question, the facility did not remove the GNA from the resident care area while the abuse allegation was being investigated.
A resident with quadriplegia and intact cognition reported via email to the Administrator that $85.00 was taken from their wallet while they were out of the facility in the hospital. The facility’s abuse, neglect, and exploitation policy required an immediate investigation of any allegation or suspicion of exploitation. The resident later stated they had reported the missing money immediately and had not received any response. The allegation was not reported to the state agency until a month after the resident’s email, and the Administrator acknowledged being aware of the allegation and not conducting an investigation, contrary to facility policy.
Staff failed to thoroughly investigate an allegation that a resident’s money was stolen by a GNA. When the resident reported that $150.00 was missing and implicated a specific GNA, the facility’s investigation relied solely on standardized abuse interview forms that asked only about verbal, physical, or sexual abuse, and all responses were marked negative. No residents, including the reporting resident’s roommate, were asked about missing property, prior incidents of missing belongings, or concerns related to the implicated GNA. The DON later confirmed that only the abuse questionnaires were used and that residents were not questioned about the specific allegation of theft because those were the forms they had been told to use.
The facility failed to follow its abuse prohibition policy by not interviewing the CNAs assigned to a resident after the resident, who had muscle weakness and intact cognition, alleged neglect and rough care during the night shift. Although the resident reported being left in bed without a bath or assistance, experiencing rough care from a female aide, and having the call light turned off, the investigation only included statements from two RNs and one CNA who was not among the staff assigned during the reported shifts. Staffing records showed specific CNAs were assigned to the resident during the timeframe of the alleged incident, but these primary care staff were not interviewed, despite the DON’s acknowledgment that such interviews are typically part of an abuse investigation.
A resident experienced an unwitnessed event reported by the spouse, who found the resident’s legs hanging off the bed and repositioned them. The resident later complained of left leg pain and was sent to the ED, where an acute left hip periprosthetic fracture was diagnosed. The facility subsequently discussed the case in a risk meeting and documented that no fall occurred, but did not conduct a timely or thorough investigation at the time of the event to determine how the injury of unknown source occurred, relying instead on an assumption about the spouse’s actions.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with dementia and severe cognitive impairment (BIMS 5/15). A construction foreman reported that construction staff had previously heard crying and pleas for help from the resident’s room and believed they saw a staff member striking an elderly wheelchaired patient, and later again heard crying, pleas for help, and slapping sounds from the same room before notifying facility staff. The DON identified the alleged perpetrator as a private duty assistant hired by the resident’s family and acknowledged that the facility had no HR records for this individual, including abuse training, background checks, or licensing information, and that the facility’s investigation did not include separate interviews with each construction staff member.
Staff failed to immediately remove a GNA from resident care after verbally abusing a cognitively impaired resident with dementia. During an evening shift, the GNA used profane language toward the resident while providing care, but other staff present did not recognize or report the incident as abuse at the time. The DON was not informed until the following morning, and staffing records confirmed that the GNA continued working for about 10 hours with vulnerable residents after the incident occurred.
A resident reported by email to the administrator and DON that two GNAs made comments about them as if they were not present while providing care. The administrator later acknowledged that the email was received but not reviewed because she was out sick and the DON was at a hearing, and both stated they missed the message. As a result, the resident’s allegation of verbal abuse was not addressed or investigated by facility staff.
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