The facility failed to conduct a thorough investigation of a resident-to-resident sexual abuse allegation after a nurse observed a resident with dementia place his hand under another cognitively impaired resident’s shirt and touch her breast in a TV lounge. Although both residents had care plans identifying vulnerability and the need to report suspected maltreatment, the facility’s internal investigation did not include comprehensive interviews with all involved and potentially knowledgeable staff, such as the witnessing RN, the assigned RN, and a NA who had assisted and seated the residents, nor were other nearby residents interviewed. The DON and Administrator, who were responsible for the investigation, could not provide documentation showing that required elements of the facility’s abuse investigation policy—such as full staff and resident interviews and complete assessment of the circumstances—were completed.
A resident with diabetes and multiple comorbidities experienced a medication error when rapid-acting insulin Aspart was administered at an incorrect time and then documented inconsistently by two RNs on the eMAR. Blood glucose readings and eMAR entries showed high glucose levels with 15 units of Aspart recorded at midday and later in the day, while one RN reported actually giving the insulin mid-afternoon and instructing another nurse to chart it as given earlier. That evening, the resident was found weak, cold, clammy, incoherent, and hypoglycemic, was treated with juice, and then sent to the hospital, later becoming unresponsive. The RN involved reported the error to the DON, but the DON and Administrator acknowledged that no medication error form was completed, no clear investigation was conducted, no re-education was provided, the incident was not reported, and no investigation policy was produced when requested.
A resident with dementia, depression, psychotic disorder, and moderate cognitive impairment, dependent on staff for all cares, was allegedly subjected to verbal and physical abuse by a NA during evening cares, including aggressive, profane language and an open-hand smack to the bare buttock while the resident cried and whimpered. Two staff members reported the incident to a charge LPN that evening, but the LPN did not immediately notify the on-call nurse, did not ensure the resident’s immediate safety, and did not document or complete a timely skin or behavior assessment. The alleged abuser continued working with residents until the next morning, and when the investigation was later initiated, it was limited to interviews of a small number of verbally responsive residents, without documented skin checks or behavior chart reviews for non-verbal residents and without interviewing all relevant night staff, contrary to the facility’s maltreatment reporting policy.
Two residents with cognitive and mobility impairments experienced alleged verbal, mental, and physical abuse, as well as neglect of care, by nursing assistants. Facility staff failed to promptly investigate, report to the State Agency, or implement resident protections, and did not suspend the alleged perpetrators or conduct thorough interviews with other staff or residents. Documentation and communication gaps were identified among the administrator, DON, and other staff, resulting in incomplete investigations and lack of timely action.
A facility failed to thoroughly investigate an allegation of physical abuse when a cognitively intact resident was punched by a nursing assistant during care. Although staff interviews were conducted, no residents or families were interviewed about the incident, and the investigation did not include residents from other units where the staff member had worked. The facility's policy requiring comprehensive interviews was not followed.
A resident with severe cognitive impairment and on anticoagulant therapy developed significant bruising and hip pain of unknown origin. Despite multiple staff observations and documentation of pain and bruising, there was a delay in reporting the injury to authorities and initiating an investigation. Staff interviews revealed incomplete documentation and lack of timely communication with the provider and DON, resulting in a deficiency for failure to respond appropriately to an alleged violation.
A resident with mild cognitive impairment and a history of behavioral disturbances made multiple allegations of physical and sexual abuse. Despite these reports and the facility's policy requiring formal investigation of all abuse allegations, staff did not initiate a formal investigation, citing the resident's history of similar claims and existing preventive measures such as the buddy care system.
A resident with severe cognitive impairment fell from a ceiling lift during a transfer when a sling strap was not fully secured, resulting in head and arm injuries. After the incident, the same lift was used for additional transfers, and staff involved continued to perform transfers before receiving retraining or competency checks, contrary to facility policy requiring removal of equipment and staff restriction pending investigation. This failure exposed other residents needing total body lift transfers to potential harm.
A resident with severe cognitive impairment was physically restrained and given morphine against her wishes by an RN, despite her care plan directing staff to respect her treatment decisions. Staff reported the incident, but the DON did not interview the involved nurse or follow up with the resident or other staff, and no immediate protective actions were taken. The facility's abuse prevention policy requiring immediate investigation and protection was not followed.
A resident with severe cognitive impairment and multiple physical conditions was injured during a staff-assisted transfer when a gait belt was not used as required. The staff member involved used improper technique and admitted to not following proper procedures. The facility did not complete a thorough investigation or root cause analysis, failed to interview other potentially affected residents, and did not remove the staff member from resident care duties during the investigation, contrary to facility policy.
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