Finding Description
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, staff interview, and resident interview, the facility failed to protect the resident's right to be free from abuse for three of three (Resident (R) 80, 359, 78) reviewed for abuse of 41 sampled residents. This failure to protect the residents increased the risk of further exposure to abuse.
Findings include:
Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25, revealed, Policy It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. Cadia Healthcare adopts this policy to standardize procedures for employee screening, employee training, prevention, identification, investigation, protection, and reporting of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and reasonable suspicions of crime. Purpose: To ensure that all residents are protected from abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Guidelines . Prevention: The facility will; Provide residents and staff information on how to report concerns and incidents without fear of retribution. Provide training to ensure resident rights and safety are met. Monitor staffing patterns in relation to reported allegations or suspicions of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Protection: The facility will respond immediately to protect the alleged victim, the integrity of the investigation and provide protection from retaliation. Assessment of the alleged victim will be conducted for signs and symptoms of injury (physical and/ or psychosocial). Increased supervision, room changes, and staffing changes may be provided to the alleged victim and other residents. Psychological support will be offered during and after the investigation. The named person accused of the act will be immediately suspended pending outcome of the investigation. Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately . The DON (Director of Nursing) or designee is responsible to conduct the abuse investigation. The NHA (Nursing Home Administrator) serves as the abuse coordinator. Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours. Incidents involving reasonable suspicions of criminal conduct are reported to the applicable state agency and law enforcement within 8 hours or within 2 hours if the conduct causes serious bodily harm .
1. Review of R80's undated admission Record, located in R80's electronic medical record (EMR) under the Profile tab, revealed R80 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified dementia with agitation, major depressive disorder.
Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24, located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R80' was cognitively severely impaired.
Review of the facility investigation, started 07/11/24, revealed the incident occurred on 07/07/24 when Certified Nursing Assistant (CNA) 1 stuck her tongue out and threw three wipes toward R80's head while in the process of changing the resident. R80 then attempted to throw spit at CNA1. CNA2 witnessed the incident and she and CNA1 left the room. CNA2 reported the incident to Licensed Practical Nurse (LPN)1 on 07/07/24. The incident was not reported to the Abuse Coordinator until 07/11/24.
Failing to report the allegation of abuse allowed CNA1 to remain on schedule and she worked 07/08/24, 07/10/24, 07/11/24.
Phone interview on 03/13/25 at 12:26 PM CNA2 stated, R80 was aggressive like normal when we went to change her. Then CNA1 threw three individual wipes at R80's face, R80 then spit in her hand and threw it at CNA1. After that we both walked out of the room, and I went to tell the nurse (LPN1) what happened. I went back to check on R80 and she was fine, she didn't say anything about it.
During a phone interview on 03/13/25 at 1:20 PM, the former Administrator stated, The CNA was suspended during the investigation and later terminated. By terminating her we would have confirmed the abuse. The DON performed the investigation.
2. Record review of facility provided documentation and resident record review revealed one incident of resident-to-resident aggression with R17 as the assailant. On 06/12/24, R78 was revealed to have informed the facility that they had been struck by R17 on 06/11/24, the previous day.
Review of R17's electronic medical record (EMR) Profile tab, revealed admission to the facility on [DATE] with diagnoses of syncope and collapse, undifferentiated schizophrenia, epilepsy, and major depressive disorder recurrent/moderate.
Review of R17's quarterly MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS score of nine out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. The incident of resident-to-resident behavior occurred 06/11/24.
Review of R17's annual MDS under the MDS tab of the EMR, with an ARD of 01/29/25, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident.
Review of R17's Care Plan in the EMR under the Care Plan tab, initiated 02/17/23 and last revised 08/02/23, revealed R17 had the potential to have socially inappropriate behavior with the potential for physical resistiveness towards others as evidenced by scratching, swinging, kicking, pushing, and/or slapping. Interventions identified prior to the incidents below, to allow ten to 15 minutes for the resident to calm down then reapproach, approach calmly and unhurriedly, to avoid overstimulation, and to explain all care tasks prior to providing care.
Review of R78's EMR Profile tab, revealed admission to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and anxiety disorder.
Review of R78's annual MDS under the MDS tab of the EMR, with an ARD of 05/03/24, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed R78 had no behaviors nor rejected care. The incident of resident-to-resident behavior occurred 06/11/24.
Review of R78's quarterly MDS under the MDS tab of the EMR, with an ARD of 01/31/25, revealed a BIMS score of ten out of 15 which indicated moderate cognitive impairment. Further review revealed that R78 had no behaviors nor rejection of care. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident.
Review of R78's Care Plan in the EMR under the Care Plan tab, initiated 09/29/23 and last revised 11/08/23, revealed R78 had the potential to be verbally aggressive (yelling and cursing) to staff and make false accusations of staff not providing care when all needs were met. Interventions identified prior to the incident below were to provide paired care for the resident, assess the resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation, to assess and anticipate the resident's needs, and when the resident becomes agitated, to intervene before agitation escalates and guide away from source of distress.
Review of the facility provided the Incident Report that documented on 06/12/24 at 1:30 PM, that there was a resident-to-resident abuse situation between R17 and R78. The incident was unwitnessed, and the resident representatives and the physician were notified timely. R78 stated that on 06/11/24, the day prior, R17 had stood over her and hit her in the face. She reported that the incident occurred during the night of 06/11/24 and that R17 had used her open hand and struck her in the forehead. She also stated that this was the first physical altercation with R17.
The investigation of the 06/11/24 incident revealed no injuries to R17. R78 was sent to the hospital for a psychological evaluation on 06/12/24 and was readmitted on [DATE] with no new physician orders. R17 was readmitted to a different room. R78 was followed by psych services, with no deviation from baseline. Other facility residents were interviewed to determine if they had experienced any abuse, and there were no identified concerns. Staff were also interviewed with no identified concerns.
The investigation revealed the interventions after the resident-to-resident included sending R17 to the hospital for psychiatric evaluation upon notification of the incident, a room change, and in-house psychiatric follow-up. No additional observations or reported incidents of resident-to-resident abuse have been documented between R17 and R78 since the event on 06/11/24.
During an interview on 03/10/25 at 4:13 PM, R17 stated that she was not fearful of any residents or staff in the facility, including R78. She stated she was satisfied with her private room. She was unable to recall the resident-to-resident incident.
During an interview on 03/11/25 at 11:18 AM, R78 stated she had a previous concern with a former roommate. She was unable to recall the resident's name, but stated she was not afraid of the other resident or anyone else. R78 said she was not bothered by the incident from 06/11/24 and had no concerns that she wished to discuss.
During an interview on 03/14/25 at 11:25 AM, the Assistant Director of Nursing (ADON) said that she had completed the initial report for the resident-to-resident incident, but the former Director of Nursing had completed the investigation. She stated that staff would have told her what happened, reported the incident, and she would have informed the former Director of Nursing. She said she had two hours to report it and the investigation would have had to be done in five days. She stated that she would expect to see interviews with the residents involved, any witnesses, and staff. She said the facility would have gotten statements with other residents to see if they had any problems with the residents in the incident. She stated that there were no problems at all. She said the residents lived on separate hallways. The ADON said that R17 had her own room since the incident, and there had been no further issues. She said that R17 was able to be moved into a new room right away because there was open and available at the time of the incident.
During an interview on 03/14/25 at 2:23 PM, the Director of Nursing (DON) stated she had not been in her current position during the time of the incident. She stated R17 did have behaviors, but the facility staff had been able to redirect her. The facility provides emotional support. Whenever they see the resident cycling or ramping up with behaviors, they have psych services see her again, to which she is usually agreeable. The resident was provided with her own room because she has had some roommate problems in the past, due to personality conflicts. She said R17 liked and did best in her own room. She does come out of her room, is social, circles around the nurse station, and sometimes goes to activities. The DON stated that staff have been trained to redirect her and provide her support because they want staff to deescalate the situation and makes sure all residents are safe. She stated dementia training was provided upon new hire and annually so they can handle difficult behaviors. She said that R78 has no ongoing behavioral issues and has done well with her new roommate. She said that if staff see abuse, she wants them to report it immediately so she can report it immediately and do the investigative process. The DON said she wants residents to be safe, and to separate them if there is a resident-to-resident behavior. She stated that if there is any incident they will begin behavior monitoring until psych services can see them. She said an investigation includes interviewing staff to complete the whole investigation process. She said psych services typically get involved with resident-to-resident incidents, and that they come in regularly so the residents can be assessed.
During an interview on 03/14/25 at 3:44 PM, the Social Service Director (SSD) stated that R17 did have some paranoid behaviors and could get agitated. She said R17 had some history of agitation with other residents and staff, just yelling out. SSD said R17 was redirectable. SSD stated R17 was given her own room because she had believed that her former roommate had talked about her. SSD confirmed the resident did best in her own room. She stated that abuse training was completed by all staff upon hire and annually.
During an interview on 03/14/25 at 6:45 PM, CNA13 stated that abuse training was completely on an ongoing basis. CNA13 said R17 moved rooms, to a different unit, and had not seen any behaviors since the original incident. She stated R78 had not been observed interacting with R17 since the room change.
During an interview on 03/14/25 at 6:55 PM, Licensed Practical Nurse (LPN) 5 stated that the facility did abuse training a few times each year. He stated that he started last summer and had multiple abuse training since he had been at the facility, because the facility did not tolerate any types of abuse. LPN5 stated that if anyone saw anything that could be considered as potential abuse, anything on the body or that you notice is new, you had to report it immediately so it could be investigated. LPN5 said that there had been no identified concerns with R17 or R78 since working at the facility.
3. Review of R359's annual MDS, with an ARD of 10/08/24 and located in the EMR under the MDS tab, revealed R359 had an admission date of 10/01/24 and a BIMS score of 15 out of 15, which indicated R359's cognition was intact. The MDS assessment indicated R359 had diagnoses that included glaucoma, acquired absence of right leg above knee, and cerebrovascular disease.
Review of R359's care plan, revised 10/29/24 located in the EMR under the Care Plan tab revealed The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Activity Intolerance, RAKA [right above the knee amputation], Impaired balance, Limited Mobility, Musculoskeletal impairment/Acquired absence of right leg below the knee. An intervention included Assist with hygiene, grooming, toileting, dressing, oral care, and eating as needed.
Review of the facility investigation dated 10/28/24, provided by the facility, revealed on October 28, 2024, at approximately 2pm, the resident and [family member] reported to his assigned nurse that they were upset about events that occurred over the weekend. The nurse then reported immediately to the social worker [name] and [name] ADON The social worker then met with the resident to perform a psychosocial visit. The resident stated that his 11-7 CNA (identified as CNA10) on Friday, October 25, 2024 treated him rudely and told him he needed to clean up his room because it was a mess. He also stated later on this past weekend (resident unsure of date/time) another CNA who he could not identify yanked up his brief causing him pain. Resident stated to the social worker to talk to his [family member] [name] as she knows everything that happened now it's not fresh in his mind. [name] ADON spoke to resident's [family member] [name] who stated that the resident called her on October 26, 2024, around 12:37pm and stated his new CNA on 11-7 told him Rudely to clean up his room, but he cannot see well so he couldn't do it. [Family member] also stated that she received a call from her husband on Sunday October 27, 2024, around 21:16 pm that he had put his call light on and an aide who he did not know came in and he asked for a diaper and the aide told him to put it on himself'. When he said he couldn't, she was very rough with him and pulled the tabs tight causing him pain to his penis and scrotum. A skin assessment was completed by nursing and no injury or skin abnormality was found on the resident. DON [Director of Nurses] and ADON were able to identify the 11-7 CNA who was involved in the October 25, 2024, incident as [CNA10] who was suspended immediately pending further investigation. Further investigation revealed [name] CNA10 did tell the resident to clean up his room because it was a mess. [CNA] was subsequently terminated on October 30, 2024, related to poor customer service. DON and ADON were unable to identify who the suspected CNA was involved in the alleged October 27, 2024, incident. All cognitively appropriate residents along the hallway where R359 resides were interviewed to determine if they experienced any care concerns. Full body skin checks were also completed on other residents who could not be interviewed, and no new skin abnormalities were identified. Staff members were also interviewed and denied having any knowledge of the- in question or any other incident involving the resident or any other residents, nor did they recall any concerns, issues, or complaints from R359 when providing care.
Review of the facility's all staff training, conducted on 10/28/24, provided by the facility, revealed an abuse in-service was conducted by the staff developer in response to the abuse investigation that was substantiated for R359. The in-service included all types of abuse, reporting all suspected and alleged abuse immediately following the chain of command, writing statements, and monitoring residents involved in abuse.
Review of CNA10's statement, dated 10/28/24, provided by the facility revealed I did a double 10/25 into 10/26 11-7 . On west [hall] I enter room [number] spoke with [bed number] R359 [resident's name]. Approx. [approximately] 12:25 when doing rounds I noticed his room had been cleaned w/ [with] things in it proper place. I mentioned that his room looked cleaned and that would be nice because he might receive a visitor. That comment came from a conversation [room and bed number] bed had with [room and bed number] bed to which they included me in saying that they were roommates at one point and that [room and bed number] would be visiting him [R359 room and bed number]. Later that morning [room and bed number] became bothered by the comment and reported some what of the truth to the RN [registered nurse] at the desk. I was informed not to enter that room.
Review of the ADON's statement, dated 10/28/24, provided by the facility revealed I sat down with CNA10 to discuss the complaints from R359 and his [family member] [name]. I explained to her that they were very upset about way she talked to him, on October 26 at 12:37 in the morning. She [CNA10] stated to me that his room was a mess. that there were papers and trash on the floor and she did tell him that the room was disgusting and he needed to clean this mess up in case he had visitors.
Review of CNA10's personnel file provided by the facility, revealed CNA10 was suspended pending the investigation on 10/28/24 and terminated on 10/30/24 due to poor customer service.
During an interview on 03/12/25 at 2:13 PM, the ADON stated she became aware of the allegation by another staff member. The DON asked her to conduct skin assessments and interviews. The ADON stated she didn't remember specifics as it's been too long ago but she obtained a statement from CNA10. The ADON stated CNA10 admitted to her she told R359 his room was a mess; his room was disgusting and he needed to clean this mess up in case he had visitors. The ADON stated after further investigation they determined there was only one perpetrator.
During an interview on 03/12/25 at 6:11 PM, the Administrator and DON stated safe surveys were completed on residents that had contact with CNA10 with questions about abuse and safety. The DON stated staff were also interviewed and statements were obtained from those who had worked with CNA10.
During an interview on 03/13/25 at 6:26 PM, the SSD was asked about R359's investigation. SSD stated staff alerted her to R359's room as he had a complaint and was upset. SSD stated R359 told her his CNA pulled on his brief, and it was hurting him. SSD stated R359 didn't remember the details, but he had told his [family member] earlier. SSD stated she reported it immediately and the ADON called the [family member]. SSD stated she understood there was only one perpetrator identified and that it was CNA10. SSD stated R359 had no lasting pain from the brief.
During a follow up interview on 03/13/25 at 6:30 PM, the ADON stated the timeframes helped substantiate that there was only one perpetrator, CNA10. ADON stated they compared the nursing schedule using a 72-hour timeframe and statements were taken from all nursing staff. R359 had no roommate, and there was not a second staff member present to witness care.
During an interview on 03/13/25 at 7:00 PM, DON stated the ADON told her about R359's complaint and they started putting the pieces together by comparing schedules and assignment sheets. DON stated, just one person was identified, and a second person could not be substantiated. DON stated R359 wasn't certain CNAs by name and by process of elimination they figured it out. DON stated she didn't get the impression CNA10 meant any harm in her interactions with R359, and they couldn't prove his brief was pulled off abruptly as R359 had no injury or redness.