A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
Staff failed to implement abuse-prevention and supervision policies for a cognitively impaired, behaviorally disturbed resident who repeatedly engaged in aggressive and sexually inappropriate conduct toward other severely cognitively impaired residents on a Memory Care Unit. In separate incidents, one resident was pushed to the floor and sustained a head bump after a slap-and-push altercation, another cognitively impaired female was found in bed with the aggressive male resident while her brief was displaced and her buttocks exposed, a male resident with dementia suffered a lip laceration after being struck, and a female resident on anticoagulant therapy developed significant bruising and swelling to her eye after reporting she was hit during a struggle over a reacher/grabber. Despite facility policies requiring individualized supervision, hazard mitigation, and protection from abuse, the aggressive resident continued to ambulate freely throughout the unit with direct access to other vulnerable residents, and staff and leadership acknowledged that such resident-to-resident altercations and non-consensual bed-sharing constitute abuse.
Staff failed to implement abuse and neglect prevention policies for a cognitively impaired, ambulatory resident with known wandering and exit-seeking behaviors, resulting in an elopement from an unsecured, unalarmed courtyard and multiple sexual contact incidents with other residents. Despite a physician order for a Wander-Gard and care plan focuses for elopement risk, behaviors, and 1:1 monitoring, the device was not consistently in place, interventions were not implemented or documented, and staff were unaware of the 1:1 requirement. The facility’s courtyard gate alarm was turned off with unaccounted-for keys, and an elopement and a later incident where the resident entered a female resident’s room without pants were not reported to the state agency. For a separate sexual incident between two residents, the facility produced only limited documentation, could not locate the initial facility-reported incident, had no confirmation of a 5-day follow-up being sent, and had no investigation notes or staff statements, despite a policy mirroring federal and state abuse/neglect reporting requirements.
Abuse occurred when an LPN attempted to obtain a urine specimen from a cognitively impaired resident by catheterization and two CNAs held the resident down while he resisted, resulting in bleeding, hematuria, and hospitalization. The facility also did not verify licenses at hire for multiple staff members, despite stating that license verification is part of its abuse prevention program.
A resident with stroke, chronic systolic HF, left-sided hemiparesis, aphasia, and moderate cognitive impairment (BIMS 7) was allowed to leave on an LOA with a person identified as a cousin, after being signed out and assisted by a CNA who was not trained on the LOA process. Staff, including an LPN and the Manager on Duty, believed the resident was going to a cookout and would return later that day, but the resident did not return and remained away for about three days without the knowledge of nursing staff or family. The resident’s daughter learned he was missing only when contacted by staff, and a missing person report was filed with local law enforcement. Although facility policy required prompt reporting of unusual incidents and submission of a 5‑day investigative report to the state agency, no such reports were made; instead, the state agency received an anonymous complaint and later a call from the resident. The facility’s internal investigation was incomplete and did not include all relevant statements or a full chronology of events.
The facility failed to follow its abuse prevention and injury-of-unknown-origin policies when a resident with dementia and weakness was found on the floor, unwitnessed, complaining of right leg pain and unable to perform active ROM. The resident was sent to the hospital and underwent a right partial hip replacement for a fracture, but the former Administrator did not complete a reportable incident within 24 hours, believing it was related to a fall rather than an injury of unknown origin, contrary to facility policy requiring such injuries to be reported and investigated.
Failure to timely report resident-to-resident altercations: A resident was involved in two altercations with another resident, including one where the roommate reported being punched in the face and another where the resident struck a peer in the face with a padded sewing box. The facility’s abuse policy required reporting abuse allegations within 2 hours, but state agency notification was documented the next day for both events. Staff interviews confirmed they knew these incidents had to be reported immediately and within 2 hours, and the DON stated the incidents were probably not brought to her attention until the next day.
Facility staff failed to follow their abuse reporting policy for a resident involved in multiple resident-to-resident altercations, including an incident where the resident held a butter knife while yelling at another resident and another incident where the resident was struck from behind and struck back. Documentation review showed that required investigation summaries were not sent to the Ombudsman or APS, despite a written policy directing the Administrator to report all alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to state agencies, APS, the local Ombudsman, and law enforcement within specified time frames.
Facility staff did not follow required procedures for timely reporting and thorough investigation of multiple abuse, neglect, and theft allegations. In several cases, incidents were not reported within the mandated timeframe, and investigations lacked interviews with all involved parties and witnesses, resulting in incomplete documentation and failure to meet policy standards.
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