Incomplete Investigation of Missing Fentanyl Patches and Failure to Report Misappropriation
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into two missing Fentanyl transdermal patches prescribed for chronic pain for Resident #73, who had diagnoses including hemiplegia and malignant neoplasms of the bladder and prostate, and impaired cognition per the MDS. Physician orders directed application of a 50 mcg/hr Fentanyl patch every 72 hours. On the date of the incident, the former DON was notified by the night nurse of two missing Fentanyl patches, but the investigation documentation lacked basic elements such as the time of notification and complete staff statements. The investigation file contained only four statements from selected nursing staff and did not include a statement from the night LPN who initially reported the missing patches or from the LPN who oriented with the nurse that signed for the patches. The statement attributed to the LPN who received the pharmacy delivery was only present as an unsigned email from the Administrator. Only three staff members were drug tested two days after the incident, while other involved nurses, including the RN who counted narcotics with a day-shift LPN and the orienting LPN, were not tested. The former DON documented that the investigation was inconclusive and suggested the patches were likely disposed of when bags were thrown away, without supporting documentation. Multiple interviews confirmed that the two Fentanyl patches were never found and that the incident was not reported to the state survey agency via a Self-Reported Incident, to law enforcement, or to the pharmacy, despite facility policies requiring investigation and reporting of alleged misappropriation and controlled substance discrepancies. The pharmacist confirmed he was not notified of any missing narcotics and stated he should have been. The facility’s Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and Controlled Substances policy require immediate reporting of such allegations to the Administrator, ODH, and law enforcement when a crime is suspected, as well as consultation with pharmacy and documentation of the investigation. These policy requirements were not followed in this case, resulting in a deficient, incomplete investigation of the missing Fentanyl patches for Resident #73.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and intact cognition, who had elected video monitoring in the room, was the subject of a personnel corrective action in which an LPN was documented as having shouted at the resident using foul language and later drew a written concern from the resident’s family member about the LPN’s behavior. The behavior was characterized in the personnel record as disrespectful, abusive, and unprofessional, and leadership acknowledged it met criteria for a self-reportable abuse incident. However, there was no documentation of verbal abuse in the resident’s progress notes and the facility could not produce evidence that any investigation was conducted, despite a policy requiring immediate investigation of suspected or reported abuse.
A cognitively impaired resident with dementia and depression reported that a male CNA attempted a sexual act during personal care, identifying him by name and clothing. An LPN, social worker designee, and HR director were involved in the initial response, and the CNA was told to leave the building that day. However, the facility’s investigation consisted only of brief, non-witness staff statements, lacked detailed accounts from key involved staff and the CNA, and included no documentation of the allegation in the medical record. The facility concluded no abuse occurred based largely on the resident’s son’s comments, did not report the allegation to the state agency as required by policy, and allowed the CNA to return the next shift as a shower aide, providing care to multiple other residents before being removed from duty when a later formal allegation was made.
A resident with severe cognitive impairment and multiple comorbidities, who was dependent on staff for most ADLs, was found by family to have a light purple discoloration/bruise on the right cheek during care. The RN on duty had not previously noted the area and reported it to the DON, who suggested it might have been caused by contact with a bedrail but did not clearly document the nature of the incident. The facility’s investigation was incomplete: staff interviews lacked dates and times, one CNA’s phone statement omitted full identification, no abuse-related physical assessments were performed on other non-interviewable residents, the incident/accident log did not reflect the bruise, and no skin assessment or documentation of the bruise appeared in the resident’s medical record, despite policy requiring thorough abuse investigations with written statements from all involved.
A cognitively intact resident with multiple chronic conditions reported that his medications, specifically pain medications, were being taken while he was being transported to the hospital. The facility’s self-reported incident stated that a thorough investigation was completed and the allegation was unsubstantiated, but the investigation file contained no staff interview statements and no documented interview with the resident to clarify which medications were involved or when they were taken. The DON and a UM confirmed that no formal statement was obtained from the resident before or during his hospital stay, and no staff interviews were documented, contrary to facility policy requiring comprehensive investigative interviews and documentation for alleged misappropriation.
Two residents with severe cognitive impairment were involved in separate incidents where the facility failed to follow its abuse and injury investigation policies. In one case, a family member reported video evidence of a CNA kicking a bed, but the facility’s investigation included only the CNA’s statement and a census checklist, with no documented interviews of other staff or individualized resident responses, and key clinical leadership were not notified as required. In the other case, a resident was observed with a large purplish-red forearm bruise of unknown origin; staff had not documented the bruise, performed an assessment, reported it, or initiated an investigation, despite policy requiring investigation of injuries of unknown source.
Two residents were involved in an alleged incident of sexual abuse when a cognitively intact male resident with a known history of sexually inappropriate behavior was observed by a CNA standing in front of a severely cognitively impaired female resident in a hallway with his pants halfway down and his genitals exposed, telling her to look. The female resident affirmed that he had shown his genitals and was later overheard saying she was scared. A police report documented that staff reported the male resident exposing himself, although he denied the behavior. Despite this, the facility’s internal SRI concluded the allegation was unsubstantiated, stating there was no behavior suggesting concerning interaction and that the cognitively impaired resident could not provide a statement. The Administrator later acknowledged that his recollection of the event (pants down and genitals exposed) conflicted with the SRI, that not all involved staff provided witness statements, and that sexual abuse could not be ruled inconclusive, indicating the investigation was not complete or thorough as required by facility policy.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident. The resident had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, and had intact cognition per a quarterly MDS assessment. The resident’s care plan documented that he had elected to have video monitoring in his room. A Corrective Action Report (CAR) in an LPN’s personnel file, signed on 01/01/26, stated that on 12/01/25 the LPN 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 the LPN’s behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the behavior described in the CAR met criteria for a self-reportable incident due to abusive behavior. The Administrator initially stated she could not determine which resident was involved in the incident, while the Human Resources Director confirmed that the resident with video monitoring was the resident affected by the LPN’s behavior. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. The Administrator later confirmed that the facility could not provide evidence of any investigation into the incidents involving the resident and the resident’s family member, despite the facility’s abuse policy requiring an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. This lack of investigation was identified as an incidental finding during a complaint survey.
Failure to Thoroughly Investigate Sexual Abuse Allegation and Protect Residents from Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident sexual abuse and to protect residents after the allegation. A cognitively impaired resident with severe dementia, depression, and a history of occasional delusional thinking reported that a male staff member attempted to put his "thing" in her mouth, gesturing toward her own and the nurse’s private areas. The resident identified the alleged perpetrator by name and described his clothing, which matched that of a male CNA on duty. The resident appeared upset and was yelling when initially interviewed by the social worker designee and human resources director, and later became guarded and defensive when asked by surveyors about the incident, stating she had been told she was safe and that the man would no longer care for her, and that she was told not to discuss the incident. Staff actions and documentation on the date of the allegation were incomplete and did not meet the facility’s own abuse policy. The LPN caring for the resident was informed by the CNA that the resident was combative during care and, upon assessing the resident, heard the resident’s statements about the attempted sexual act. The LPN reported the concern to the social worker designee because administration was not yet on site. The social worker designee and human resources director interviewed the resident, confirmed the description of the CNA’s clothing, and notified the Administrator by phone. The Administrator, via speaker phone, directed that the CNA leave the facility pending investigation, and the CNA clocked out that morning. However, the facility’s internal investigation file for that date contained only brief, non-witness statements from other staff attesting that they had never seen the CNA be abusive, and lacked detailed statements from the social worker designee, human resources director, the LPN who received the allegation, or the CNA accused. There was no documentation in the medical record regarding the resident’s allegation or the events of that day. The facility’s investigation summary for the date of the allegation concluded that the resident was confused and combative during personal care and that no abuse occurred, relying in part on the resident’s son’s statement that the resident behaves that way when she has a UTI and that he did not think an investigation was warranted. The assistant DON confirmed that no deeper investigation was conducted and that the incident was not reported to the state agency, despite facility policy requiring reporting of any allegations or suspicions of abuse prior to investigation. Furthermore, after being sent home the day of the allegation, the CNA was allowed to return to work on the next scheduled shift and was assigned as a shower aide on a different unit, providing care to eight other residents while the initial allegation had not been fully investigated or reported. The DON and ADON verified that the CNA worked that full shift with resident care responsibilities before being placed on leave when a formal allegation was later made by the resident’s son.
Failure to Thoroughly Investigate Injury of Unknown Origin and Document Findings
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an injury of unknown origin involving a resident with severe cognitive impairment and extensive care needs. The resident, admitted with diagnoses including Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, required substantial/maximal assistance with eating and bed mobility and was dependent on staff for bathing, hygiene, and transfers. The resident’s care plan included monitoring for skin concerns during care. On the date of the incident, the resident’s daughter observed a light purple discoloration/bruise on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not noticed it earlier and reported it to the DON. The DON’s incident report suggested the area could have been caused by the resident’s cheek resting on a side rail during incontinence care, but the nature of the incident was not clearly documented. The facility’s investigative process was incomplete and poorly documented. Staff interviews did not reveal any evidence of the resident’s face contacting the bed rail, and the interviews with multiple CNAs lacked dates and times. One CNA’s witness statement, obtained by phone, did not include her last name or title. No physical assessments for abuse were conducted on non-interviewable residents to determine if others were affected. The incident/accident log contained no entry for the resident’s cheek bruise, and the resident’s medical record had no documentation of the bruise or a skin assessment on the date it was identified. The DON confirmed that the incident report constituted the full investigation, that no other residents were assessed for injuries, that no written staff education was completed for prevention of recurrence, and that there was no medical record documentation of the discoloration/bruise, despite facility policy requiring all abuse investigations to be thoroughly investigated with written statements from all involved parties.
Failure to Thoroughly Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation involving one resident. The cognitively intact resident, who had multiple medical diagnoses including muscle wasting and atrophy, COPD, hypotension, severe sepsis, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, CHF, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder, reported that his medications were being taken while he was being transported to the hospital. The facility submitted a Self-Reported Incident indicating that a thorough investigation had been completed and the allegation was unsubstantiated. However, review of the facility’s investigation packet revealed there were no staff interview statements and no documented interview with the resident to determine which medications were allegedly taken, when they were taken, or to obtain other specific information about the allegation. The DON and a Unit Manager confirmed that no staff interview statements were documented and that no formal statement was obtained from the resident before he left for the hospital, nor was he contacted or interviewed at the hospital. These omissions were inconsistent with the facility’s own policy, which requires thorough documentation and investigation steps including interviews with the resident, reporter, staff on all shifts, and others, as well as complete documentation of findings.
Failure to Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete investigation into an abuse allegation involving Resident #117. This resident, admitted with neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, chronic pain syndrome, and Alzheimer’s dementia, had a BIMs score indicating severe cognitive impairment and required maximum assistance with toileting. A family member reported to police that an in-room camera showed a CNA kicking the resident’s bed, prompting police and family to come to the facility. The facility’s Self-Reported Incident noted the allegation and that the resident could not provide meaningful information due to dementia, and that no negative effects were observed at the time. However, the investigation file contained only a written statement from the accused CNA and a census sheet with check marks indicating residents felt safe, without documentation of individual resident responses or how non-interviewable residents were assessed. Further interviews revealed that staff who were present when police reviewed the video, including an RN Coordinator and another CNA, were not asked to provide witness statements. The DON confirmed she could not provide written evidence of staff interviews beyond the CNA’s statement or individual resident interview responses. The Medical Director did not recall being notified of the abuse allegation. The facility’s abuse policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be investigated, including interviewing the resident, the accused, and all witnesses, and documenting evidence of the investigation. These policy requirements were not met in the handling of the allegation involving Resident #117. The deficiency also includes the facility’s failure to investigate an injury of unknown source for Resident #47. This resident, with adult failure to thrive, paranoid schizophrenia, and dementia, had severely impaired cognition and was documented as having intact skin with no bruising to the extremities in a recent NP note. She was not on anticoagulant or antiplatelet therapy. During surveyor observation, a circular purplish-red bruise approximately the size of a half dollar was noted on her right forearm, which the resident could not explain. There was no nursing documentation of the bruise, no assessment, and no investigation in the record. The Regional Director of Clinical Services and the DON confirmed that staff had not documented or investigated the bruise, and an LPN acknowledged noticing the bruise but did not report it or complete any statements. The facility’s abuse policy defined injuries of unknown source and required immediate reporting and investigation of such injuries, which did not occur in this case.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Resident #40, admitted on 04/07/16, had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was documented as severely cognitively impaired, requiring extensive assistance with activities of daily living. Resident #52, admitted on 03/20/25, had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in all ADLs. His care plan, initiated on 03/24/25, identified sexually inappropriate behaviors, including entering female residents’ rooms, with interventions focused on anticipating needs and addressing inappropriate behavior. On 01/11/26 at 9:32 P.M., a nursing note documented that Resident #52 indecently exposed himself to another resident in the hallway. The facility’s self-reported incident (SRI) and investigation dated 01/12/26 stated that Resident #52 was observed standing to the left of Resident #40 in the hallway with his pants appearing to be positioned below his waist, but asserted there were no movements, physical contact, or behaviors suggesting concerning interactions, and concluded the allegation of sexual abuse was unsubstantiated. The SRI noted that Resident #40 lacked the cognitive ability to provide a statement and that other resident interviews revealed no findings of abuse. However, a witness statement from CNA #213 documented that she saw Resident #52 standing in front of Resident #40, exposing his genital area and saying, "There you go, look at it," after which he rushed back to his bedroom when he saw her. CNA #213 reported that Resident #40 answered "yes" when asked if Resident #52 had shown his genitals and that Resident #40 was overheard telling another CNA she was scared. A police report recorded that staff reported Resident #52 exposing his genitals to Resident #40, though Resident #52 denied it. LPN #214 confirmed being told that Resident #52 exposed himself and acknowledged knowledge of his history of inappropriate sexual behaviors. The Administrator later confirmed he recalled reporting that Resident #52’s pants were down and his genitals were exposed to Resident #40, which was inconsistent with the SRI’s conclusion, and acknowledged that witness statements were not obtained from all involved staff and that sexual abuse could not be ruled inconclusive, contrary to the facility’s abuse policy requiring immediate, complete, and thorough investigation and documentation.
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