A resident with dementia and chronic respiratory failure, but assessed as having mild or no cognitive impairment, was the subject of multiple detailed email complaints from her daughter alleging that an LPN improperly administered Tramadol, intimidated the resident, failed to provide ordered meds and incontinence care, and used derogatory language, and that a CNA and another aide verbally mistreated the resident and disrespected her belongings, with an item reported stolen and video evidence referenced. Despite these repeated allegations sent to facility staff and the state agency, the only self-reported incident documented vague concerns of mistreatment, lacked specific details, did not include an interview or documented attempt to interview the daughter, relied on a generic questionnaire for the resident, and showed no effort to obtain camera footage. Facility leadership denied knowledge of the reported abuse, neglect, and misappropriation, the concern log contained no entries for this resident, and the call log lacked documentation of call outcomes, all contrary to the facility’s abuse policy requiring immediate, thorough investigation and reporting of all such allegations.
The facility failed to assess and document sexual consent capacity and to implement effective protective monitoring for a cognitively impaired resident involved in two separate sexual incidents with two different male residents, both of whom also had cognitive impairment. In the first incident, a CNA found the female resident in a male resident’s bed with both of their pants down and the male on top of her; this male had dementia, a BIMS score indicating cognitive impairment, a diagnosis of high-risk heterosexual behavior, and a court-appointed guardian, yet no consent-capacity evaluation or related care plan interventions were in place. In the second incident, staff found the same female resident naked in another male resident’s room, with that resident naked and inserting his fingers into her vaginal area while stating she wanted it, again without any prior assessment of either resident’s capacity to consent. Although the female resident’s care plan later referenced 15-minute checks, multiple CNAs and an agency RN working on the unit reported they were unaware of any special monitoring, and leadership acknowledged they relied only on BIMS scores for consent decisions, had not completed formal consent-capacity assessments, had not reported the first incident to the state, and were not following a clear protocol for alleged sexual abuse as required by the facility’s abuse policy.
The facility failed to thoroughly investigate multiple allegations of misappropriation of resident funds involving several cognitively impaired and cognitively intact residents. Unauthorized online purchases were made for clothing, electronics, snacks, personal care items, and activity supplies using resident trust accounts without resident or representative consent, and documentation of these purchases was absent from medical records. Some items bought with resident funds were not received by the residents and were instead found in the activities department or could not be located. Former business office, activities, and social services staff, as well as facility leadership, had access to and approved these orders, yet not all potential perpetrators were investigated, and suspicions raised by a staff member were not promptly reported to administration or corporate leadership, contrary to facility policies requiring resident authorization and thorough investigation of misappropriation.
Facility staff failed to thoroughly investigate an allegation of neglect related to a resident’s death. A cognitively intact resident with multiple comorbidities and a full code status was found unresponsive and without vital signs by an LPN during morning med pass, with no prior documented change in condition or record of when the resident was last checked. Staff interviews indicated that an agency CNA assigned to the resident was frequently unavailable, did not consistently respond to call lights, and last checked the resident around midnight to 1:00 A.M., with no further checks before the resident was found unresponsive at 5:30 A.M., despite an expectation for at least q2h monitoring. The DON acknowledged that the resident was not checked in a timely manner, that such a lapse would be considered neglect, and that no investigation or required reporting of the alleged neglect and death had been completed in accordance with facility policy.
A resident with moderate cognitive impairment, multiple chronic conditions, and total dependence on staff for mobility and ADLs was found on the floor and subsequently had multiple negative x‑rays of the right arm, leg, and hip despite ongoing pain. A later hip x‑ray showed a cortical breach and recommended a CT, and a subsequent CT revealed a nondisplaced right intertrochanteric femur fracture of unknown origin. The DON could not determine whether the fracture was related to the fall or occurred during routine care and acknowledged that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency, despite facility policy requiring identification, investigation, and reporting of possible abuse, neglect, or mistreatment.
Two residents with a history of conflict over TV volume, one highly dependent with hemiplegia and bleeding risk and the other with documented aggressive behaviors, were placed together in a shared room despite prior threats by the more independent resident to shoot his roommate. The dependent resident later reported being punched or slapped while in bed, and the aggressive resident admitted to hitting him, with staff observing the dependent resident as scared and later noting bruising to his shoulder and arm. However, the DON’s late entry progress note minimized the event as a verbal dispute with no harm, no timely injury assessment or witness statements were obtained, CNAs were not asked for statements, and there was no documented, timely abuse investigation as required by the facility’s abuse policy, resulting in a failure to thoroughly investigate the abuse allegation.
The facility failed to thoroughly investigate an injury of unknown origin for a dependent, long‑term resident with multiple comorbidities and a history of falls. After routine night care involving repositioning by a CNA, the resident yelled out during care, later complained of left knee pain, and was sent to the ER at the POA’s request, where she was diagnosed with a distal femur fracture and UTI. The resident reported that her leg had been pulled back and believed it was broken, while the CNA reported the resident resisted and screamed during rolling. The facility’s SRI concluded the fracture was likely pathological with no trauma or fall, despite a hospital note describing an acute, impacted distal femoral metaphyseal fracture due to specific trauma and a physician note referencing a recent fall with a distal femur fracture. The DON could not explain how the fracture occurred or reconcile the conflicting documentation and was unable to provide further investigative documentation, contrary to the facility’s abuse/neglect investigation policy.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and total dependence for ADLs was the subject of an alleged verbal abuse incident when a CNA reportedly raised her voice and clapped her hands in front of the resident’s face during care, which another CNA reported to the DON by text. The facility’s investigation file contained only the alleged CNA’s written account, an LPN’s statement that no aggression was witnessed, and evidence of a group text titled “Abuse and Neglect,” but lacked further investigation documentation such as additional witness statements, resident assessments, or interviews, despite facility policy requiring immediate and comprehensive investigation of suspected abuse.
A resident with dementia and multiple comorbidities was noted by an NP to have a swollen upper lip with dark purple discoloration, with conflicting explanations from the resident and staff about how the injury occurred. Nursing staff reported they did not know the cause, and an LPN who observed the swollen lip did not question the resident, notify the family, or document the injury. Chart review showed no nursing documentation of monitoring the lip as ordered by the NP, no investigation or collection of staff or resident statements, and no self-reported incident filed, despite a facility abuse policy requiring investigation and reporting of injuries of unknown source.
The facility did not complete thorough investigations into several allegations of physical and sexual abuse. In one case, two residents were involved in a physical altercation, but the investigation only included a CNA statement and no injury assessment or resident interviews. In another, a resident reported a rape-related dream after being toileted by a CNA, yet no additional staff statements or skin assessment were obtained. In a third incident, a resident alleged being hit, but the facility relied on observations that the resident was combative and that staff behaved professionally, without performing a skin assessment or interviewing all staff on that shift. The Administrator confirmed these investigative omissions, which were inconsistent with the facility’s abuse investigation policy.
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