Failure to Report Suspected Abuse/Neglect and Medication Error Involving Morphine Overdose
Summary
The deficiency involves the facility’s failure to report an alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime to state agencies as required by facility policy and regulation. The facility’s Abuse, Neglect and Misappropriation of Property policy required that any abuse allegation be reported to the state within two hours and that any reasonable suspicion of a crime with serious bodily injury be reported to the state and police. For one resident, R1, who had diagnoses including COPD, chronic pain, and osteoarthritis and who was placed on hospice care at family request, there was a medication error involving morphine dosing on the day of the resident’s death. Despite this event and subsequent involvement of law enforcement and the coroner, the facility Administrator and DON did not report the incident to the state agencies, with the Administrator stating she relied on the police to report it. On the morning of 03/12/2026, the facility NP gave a verbal order for morphine concentrate 0.25 ml every hour as needed, which she clarified as morphine concentrate 100 mg/5 ml, 0.25 ml (5 mg) every hour as needed, and she placed a written order to the pharmacy accordingly. LPN1, however, documented the order in the Physician Order Report as morphine 20 mg/5 ml, 0.25 ml (1 mg) as needed for pain. Later, a hospice nurse (HN1) wrote a hand‑written Nursing Home Visit Record increasing the morphine dose to 1.25 ml to equal 5 mg as needed, basing this on the 20 mg/5 ml concentration shown in the Physician Order Report and not on the NP’s written order to the pharmacy or the actual medication label, which both indicated 100 mg/5 ml. The morphine supplied for R1 was morphine sulfate 100 mg/5 ml concentrate, labeled to give 0.25 ml (5 mg) every hour as needed, and the Controlled Drug Record showed that on 03/12/2026, R1 received 0.25 ml at 11:30 AM and 1.25 ml at 1:46 PM, 3:11 PM, and 4:49 PM, meaning the resident was administered five times the ordered dose on three occasions. During this period, the UM and ADON expressed concern about the increased morphine dose of 1.25 ml, with the ADON instructing the UM to call hospice for clarification because the amount seemed like a lot. The UM reported she did not obtain clarification until later in the shift, and hospice documentation reflected a call at 5:10 PM questioning the order. R1 was pronounced dead at 5:53 PM that day. After the death, hospice staff raised concerns about the amount of morphine administered, reported difficulty obtaining the narcotic log, and one hospice nurse (HN2) stated she was told that the prior hospice paperwork had been shredded. The coroner and police became involved; the police retrieved the morphine, reviewed medications, and had a recorded call from the UM acknowledging that three doses had been given at five times the ordered amount. When interviewed, the DON stated that incidents to be reported to OIG would include any type of abuse and that such allegations should be brought to the Administrator, but she believed the incident was reported by police. The Administrator confirmed she did not report the allegations regarding R1 to state agencies because she knew the police were going to report the incident, even though the Medical Director acknowledged that the incident probably should have been reported. The facility’s failure, therefore, centered on not reporting the alleged violation involving potential abuse/neglect and a reasonable suspicion of a crime related to the morphine dosing error and resident death, despite clear internal policy requiring timely reporting to state agencies and, when applicable, to law enforcement. The report documents that the facility relied on law enforcement to make any required report instead of submitting its own report to the state agencies. This omission occurred in the context of conflicting morphine orders, administration of doses higher than intended based on the actual concentration, concerns raised by hospice staff and facility leadership, and subsequent involvement of the coroner and police.
Penalty
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The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse policy. A resident with multiple chronic conditions and intact cognition had elected video monitoring in the room. Video review showed an LPN shouting at the resident and using foul language, and a family member later submitted a written concern about the LPN’s behavior. The conduct was documented as disrespectful, abusive, and unprofessional, and the IDON confirmed it met criteria for a self-reportable incident. The HR director identified the affected resident, but the Administrator acknowledged that the incident was never reported to the state agency, contrary to the facility’s requirement to report abuse allegations within specified timeframes.
A cognitively intact resident with a history of vertebral compression fracture, repeated falls, and bipolar disorder alleged that an RN hurt his back while assisting him to sit up during a medication pass, becoming combative and stating he was injured. Witnesses confirmed the interaction and noted the resident’s agitation and dislike of the nurse. The DON acknowledged the resident’s ongoing issues with certain nursing staff, and the Ombudsman reported notifying the Administrator that the resident had alleged physical abuse by staff. Despite this, the Administrator did not submit a required self-reported incident to the State agency, contrary to facility policy mandating timely reporting of all abuse allegations.
The facility failed to self-report multiple resident-to-resident physical altercations as allegations of abuse to the State Agency, despite having internal documentation and an abuse policy requiring such reporting. In several separate events, cognitively impaired residents with known histories of aggressive behaviors hit or punched other cognitively impaired residents in the abdomen, head, face, or chest. Nursing staff and CNAs documented the incidents, assessed the involved residents, and noted that no visible injuries were present, although one resident reported pain. The Administrator, DON, and other clinical leadership acknowledged that internal investigations were completed but stated that no Self-Reported Incidents were submitted because they believed there was no injury and that the residents lacked intent to harm or cause mental anguish, contrary to the facility’s written abuse policy and abuse flow sheet, which defined physical abuse to include hitting and required timely reporting of alleged violations involving abuse.
A resident with severe cognitive impairment and multiple comorbidities alleged that a male CNA attempted to force sexual contact during personal care, identifying him by name and description. A social worker designee and the HR director interviewed the resident, confirmed the description matched a CNA on duty, and notified the Administrator by phone, but the incident was not documented in the medical record and was not promptly reported to the state as a sexual abuse allegation per facility policy. The internal investigation for that day lacked detailed witness statements from key staff and concluded no abuse occurred, relying in part on the resident’s son’s belief that no investigation was needed. When an SRI was later submitted, it was entered as physical abuse rather than sexual abuse, and a subsequent police report reflected conflicting information about when the facility became aware of the allegation.
A resident with severe cognitive impairment and multiple comorbidities, who depended on staff for most care, was found by a family member to have a light purple bruise on the right cheek while being assisted with lunch. The RN on duty had not previously noticed the discoloration and notified the DON, who suggested it might have resulted from contact with a bedrail during incontinence care, though staff interviews did not confirm any such contact. The incident report lacked a clear description of the event, no skin assessment or medical record entry was completed for that day, the bruise was not logged on the incident/accident log, and no self-reported incident was submitted to the State Survey Agency, despite facility policy requiring timely reporting of suspected abuse or injuries of unknown origin.
A cognitively intact resident with multiple psychiatric and medical diagnoses reported to a provider that an LPN became angry, yelled, and used profanity toward them. This allegation of verbal abuse was documented in the medical record but was not entered into the facility’s SRI system, and the Administrator was not informed, so no timely reporting or investigation occurred as required by the facility’s abuse policy and federal timeframes.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse, neglect and exploitation policy. Resident #65, who had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, was admitted on 07/23/25 and discharged on 03/02/26, with a quarterly MDS dated 01/28/26 indicating intact cognition. The resident’s care plan, initiated 07/29/25 and revised 08/12/25, documented that the resident elected to have video monitoring in his room. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. Review of LPN #221’s personnel file on 03/26/26 revealed a Corrective Action Report (CAR) signed 01/01/26 for incidents on 12/01/25 and 12/22/25, citing violations of rules of conduct and behavior. The CAR documented that on 12/01/25, LPN #221 was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described this behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the described behavior met criteria for a self-reportable incident. The Human Resources Director confirmed that Resident #65 was the resident involved. The Administrator later confirmed that the incident was not reported to the state agency, despite the facility’s policy requiring immediate reporting, but no later than two hours after an allegation of abuse is made. This deficiency was identified incidentally during a complaint survey completed on 03/26/26.
Failure to Report Resident’s Allegation of Staff Abuse to State Agency
Penalty
Summary
Failure to timely report a resident’s allegation of staff-to-resident abuse to the State agency occurred after a cognitively intact resident with a history of wedge compression fracture of the T7-T8 vertebra, repeated falls, and bipolar disorder alleged that a nurse hurt his back while assisting him to sit up in bed. On the morning in question, a CPT RN entered the resident’s room to administer medications and, according to witness statements, the resident asked for help to sit up. The nurse assisted by holding the resident’s wrists/hands while he moved to a sitting position. Witness statements documented that the resident became combative, abusive, and agitated during the interaction, and that he did not like the nurse or new staff. The nurse later reported that the resident stated she had hurt him, which she denied. The DON reported that the resident had problems with Nigerian nursing staff and specifically with the CPT RN involved. The Administrator stated that the resident did not report abuse, but rather that the nurse pulled his hands to help him up and he felt it hurt his back, and confirmed that no Self-Reported Incident (SRI) was filed with the State agency. An Ombudsman reported calling the Administrator and relaying that the resident had alleged physical abuse by nursing staff, yet an SRI was still not submitted. This inaction occurred despite the facility’s abuse, neglect, and misappropriation policy requiring that alleged violations involving abuse be reported to the State Survey Agency and other authorities within specified time frames.
Failure to Self-Report Resident-to-Resident Physical Altercations as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely self-report multiple resident-to-resident physical altercations to the State Agency (SA) as allegations of abuse, in accordance with federal requirements and the facility’s own Abuse, Neglect and Exploitation policy. For one incident, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, and obesity, who had a documented history of verbal and physical aggression, pushed and struck another cognitively impaired resident in the abdomen after the second resident slammed a dining room chair into a table and attempted to push the first resident’s wheelchair. The second resident then struck the first resident on the back of the head. Nursing notes and internal incident reports documented the altercation, assessments, and that no injuries were observed. The Administrator and DON acknowledged that an internal investigation was conducted but confirmed that no Self-Reported Incident (SRI) was filed because there was no injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s abuse flow sheet indicating that the reasonable person concept should be applied to such physical altercations. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst. They found the cognitively impaired resident who had a history of aggressive behaviors sitting on the other resident’s bed, while the room’s occupant, who had Alzheimer’s disease with late onset, psychosis, vascular dementia, and other psychiatric and behavioral diagnoses, was in a wheelchair eating dinner. The room’s occupant reported that the aggressive resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were separated and that no injuries were observed. The Administrator and DON again stated that an internal investigation was completed but that no SRI was submitted to the SA because there was no injury and they believed the residents involved did not have the ability to intend harm or cause mental anguish, even though the facility’s policy and abuse flow sheet defined physical abuse to include hitting and required reporting of alleged violations within specified timeframes. Another incident involved a resident with dementia and extensive behavioral symptoms, including exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, and other disruptive behaviors, striking a severely cognitively impaired resident with multiple medical conditions, including vascular dementia, chronic obstructive pulmonary disease, heart disease, and chronic kidney disease. According to the Incident Audit Report and a Physical Aggression Form, a CNA witnessed the aggressive resident hit the other resident in the left side of the chest with her hand in a common area and immediately redirected the aggressor. The nurse assessed the struck resident, documented no redness or bruising, and recorded vital signs within normal limits, though the resident stated that it hurt and did not know why she had been hit. The physician and family were notified, and monitoring for pain or bruising was ordered. The DON stated that no SRI was completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s Abuse, Neglect and Exploitation policy defining physical abuse as including hitting and requiring immediate reporting of alleged violations involving abuse to the SA within the required timeframe. Across these events, record review, interviews, and policy review showed that the facility consistently treated these resident-to-resident physical altercations as internal incidents without reporting them as allegations of abuse to the SA. The facility’s abuse policy and undated abuse flow sheet specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and that alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The abuse flow sheet also clarified that having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions and directed staff to use the reasonable person concept to determine psychosocial impact. Despite this, the Administrator, DON, and RN/VPOC acknowledged that SRIs were not filed for these incidents because they focused on the absence of observed injury and their belief that the residents lacked intent, rather than on the willful nature of the physical acts and the reasonable potential for injury or mental anguish as required by their own policy.
Failure to Timely Report and Properly Classify Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident sexual abuse to the state agency as required by policy. A resident with severe cognitive impairment, dementia, depression, and multiple medical conditions, who required extensive assistance of two staff for mobility and transfers, alleged that a male CNA attempted to put his genitalia in her mouth. The resident identified the alleged perpetrator by name and physical description, which matched a male CNA on duty. The social worker designee and the human resources director interviewed the resident the same morning, confirmed the description, and contacted the Administrator by phone while in the resident’s room, placing the Administrator on speaker so she could hear the interview and reported events. Despite the Administrator being made aware of the allegation on the same morning it occurred, the facility did not document the incident in the resident’s medical record and did not report the allegation of sexual abuse to the state agency at that time. The internal investigation file for that date contained only brief, non-witness statements from staff attesting generally to the CNA’s behavior, with no detailed statements from the social worker designee, the human resources director, the LPN caring for the resident, or the CNA accused. The investigation summary concluded that the resident was confused and combative during personal care and that no abuse occurred, and the facility relied in part on the resident’s son’s opinion that an investigation was not needed and that the resident might have a urinary tract infection. Subsequently, when an SRI was entered into the state’s reporting system, it was categorized as physical abuse rather than sexual abuse, and there was no SRI entered for the original date of the allegation. A police report later documented that the Administrator reported the incident as sexual in nature and stated that the facility was not made aware of the allegation until the resident’s son reported concerns, which conflicted with staff interviews confirming the Administrator’s awareness on the date of the incident. The facility’s own abuse policy required that any allegation or suspicion of all types of abuse be reported to the state agency prior to investigation, but the allegation of staff-to-resident sexual abuse was not reported as such when initially known, and the investigation was incomplete and poorly documented.
Failure to Report and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 00), protein calorie malnutrition, major depressive disorder, and chronic kidney disease was dependent on staff for most activities of daily living and required monitoring for skin concerns during care. On the date in question, the resident’s family member observed a light purple bruise or discoloration on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not previously noticed the area and then notified the DON. The DON assessed the area and suggested it could have been caused by the resident’s cheek resting on a side rail during incontinence care, but staff interviews revealed no evidence that the resident’s face had come into contact with the bed rail. Despite the family’s report and the DON’s stated intent to investigate, the incident was not fully documented or reported as required. The facility’s incident report did not specify the nature of the incident, and there was no skin assessment documented in the medical record on the date the bruise was identified. The bruise was not entered on the February incident/accident log, and review of the state’s Enhanced Information Dissemination Collection system showed no self-reported incident related to the resident’s facial discoloration for the relevant period. The DON confirmed that no self-reported incident was submitted regarding this injury of unknown origin, contrary to the facility’s abuse policy, which requires notification of the Ohio Department of Health within 24 hours and completion of an investigation within five days.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and initiate an investigation in accordance with its abuse reporting policy and federal requirements. Resident #23, admitted on 02/02/26 with diagnoses including bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder (single episode, severe, without psychotic features), and hypertension, was documented as cognitively intact on the admission MDS. The MDS also showed the resident required supervision for toileting, bathing, dressing, and transfers, setup assistance for oral and personal hygiene, and was independent with eating and bed mobility. On 02/16/26, a provider visit note signed by Former Nurse Practitioner #175 documented that Resident #23 reported an incident in which a staff member, identified as LPN #94, became angry, yelled, and used profanity toward the resident. Review of the facility’s electronic Self-Reported Incidents (SRI) system from 02/16/26 to 03/11/26 showed no alleged incidents involving this resident had been entered. During an interview on 03/11/26, the Administrator stated she had not been informed of any abuse allegation involving LPN #94 and Resident #23 and indicated she would have reported and investigated the allegation if she had been made aware. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 04/2021, showed the facility was required to investigate and report any allegations within federally required timeframes; this did not occur for the allegation involving Resident #23.
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