The facility failed to conduct and document a thorough investigation into a fracture of unknown origin for a cognitively impaired resident with osteoporosis who developed right leg pain, was sent to the hospital and diagnosed with DVT, and later was found by mobile X-ray to have an acute nondisplaced subcapital femoral neck fracture. Although the facility’s policy required comprehensive investigation of injuries of unknown source, the investigation file lacked staff and resident interviews, witness statements, and an investigative summary identifying a possible cause. The SW reported she was not directed by the DON to perform interviews, the DON stated interviews had occurred but were not formally documented, and an LPN confirmed the sequence of events and that the cause and timing of the fracture could not be determined.
A resident’s representative reported an allegation of verbal abuse, supported by an audio recording of staff cursing at the resident while the resident screamed. An RN supervisor promptly notified the DON and the Administrator, and staff who heard the recording considered the interaction abusive, but no immediate interviews of staff or other residents were conducted, no comprehensive resident assessments were documented, and protective interventions were not implemented beyond moving the resident to another unit. The DON did not come on-site until the following day, when only a single interview with the resident was completed, and contact with the representative and broader staff and resident interviews did not occur until two days after the initial report, during which time staff alleged to be involved continued providing care. The facility’s actions did not follow its abuse policy requiring prompt investigation, suspension of suspected staff, and protection of residents, leading surveyors to cite Immediate Jeopardy for failure to investigate alleged violations under 42 CFR 483.12(c)(2).
The facility failed to thoroughly investigate and promptly address two serious neglect-related events. In one event, a resident sustained a significant burn to the thigh after hot coffee was spilled, yet there was no documented effort to immediately safeguard other residents from the same coffee hazard, and a dining-room coffee machine remained accessible and operational without supervision or physical barriers despite signage. In the second event, an LPN on a night shift appeared impaired, repeatedly fell asleep at the med cart, did not complete the med pass, and residents repeatedly called for their medications while the nurse remained on duty for several hours. Audit reports later showed numerous missed and late medications for multiple residents. The DON and Administrator were aware of these incidents but did not conduct investigations consistent with facility policy, did not promptly verify medication administration through MARs or audit reports, and did not perform comprehensive interviews or root-cause reviews to prevent recurrence.
A resident with moderate cognitive impairment was found on the floor after an altercation with a nurse aide, who was reported by witnesses to have pulled a pillow from under the resident and sprayed them with an aerosol substance. Multiple staff provided written witness statements, but these were not included in the facility's abuse investigation documentation. The administrator dismissed the allegation due to conflicting accounts and lack of proof of intent, despite evidence from several witnesses.
A resident who was cognitively impaired and dependent for transfers sustained bilateral femoral neck fractures and facial bruising, with the injuries not identified until a later hospital visit. The facility's investigation into the injuries was incomplete, lacking staff witness statements, comprehensive documentation, and timely communication with the responsible party, resulting in an inability to determine the cause of the injuries.
Two residents reported being hurt or mistreated by CNAs, but despite these allegations being brought to the attention of the DON and administrator, no formal investigation was conducted as required by facility policy. The CNAs involved were removed from the residents' care, but neither resident was interviewed about the incidents, and the DON considered the complaints to be customer service issues rather than potential abuse.
A resident with a history of hallucinations and dementia exited the facility unsupervised after staff failed to respond to an audible door alarm. The resident was found outside by a dietary employee, and nursing staff were unaware of the elopement until notified. No immediate investigation was initiated, and key staff were not informed of the incident until days later, resulting in a delayed response to the event.
A resident with moderate cognitive impairment, who was always incontinent and required significant assistance, reported being scolded by a CNA for wetting the bed, resulting in feelings of shame and fear. Although the incident was reported to nursing leadership, no comprehensive investigation, follow-up, or psychosocial support was provided, and the CNA was not questioned about this specific allegation.
A resident with multiple psychiatric diagnoses exited the facility unsupervised and was found in a staff member's car in the parking lot. Staff failed to initiate missing resident procedures, did not complete an incident report, and did not conduct a thorough investigation or notify the State Agency, despite facility policy requiring immediate action for such incidents.
A resident with a history of Atrial Fibrillation and Anxiety Disorder, who was cognitively intact, alleged verbal abuse and neglect by a CNA. The facility's investigation did not include interviews with other cognitively intact residents assigned to the CNA, as required by policy, and surveillance video was not reviewed until after state agency involvement.
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