AURORA, CO- GARDEN TERRACE ALZHEIMER’S CENTER OF EXCELLENCE

Based on record review and interviews, the facility failed to report alleged violations of potential
abuse/neglect to the proper authority, including the police and state oversight agency in accordance with state law for two alleged violations out of six reported violations; involving two (#238 and #32) of 10 residents reviewed for allegations of abuse out of 40 sample residents.

Specifically, the facility failed to report two separate allegations of resident abuse by staff to the facility administrator, local police, or the State Agency, in a timely manner.

As a result, of these failures the investigative process was significantly delayed and impaired the ability of the facility investigator to secure substantial evidence towards the outcome of the investigation.

The facility investigative report dated 4/9/21 was reviewed. It documented the type of incident was physical abuse and the date was 2/24/21. The report revealed in pertinent part:
-On 4/9/2021, at 3:30 a.m. certified nurse aide (CNA) #6 reported a resident abuse, by text to a human resources representative (HRR). The HRR, had called CNA #6 to find out why he had not shown up for a scheduled shift. During the texting conversation, CNA #6 said he had witness another CNA engaging in abusive behavior towards Resident #238.
-CNA #6 alleged, on 2/24/21 around noon, he and CNA #5 were in the shower room providing Resident #238 incontinent care. The resident was not happy about receiving care and began to get snappy verbally. CNA #5 jabbed at the victim neck and back about 5 times.
-CNA #6 said he told CNA #5 to stop, CNA #5 said what does it matter? CNA #6 responded back don ‘ t do that, it makes me feel uncomfortable. CNA #6 said he removed Resident #238 from the area. CNA #6 said he reported the abuse that day, to the unit licensed practical nurse (LPN).

-The human resources representative contacted the NHA by phone on 4/9/21, after the texting conversation (see above) with CNA #6, to report the allegation of abuse to the NHA. The alleged abuse happened 2/24/21 and was not reported to the NHA, DON, police or the State Agency, within the required reporting timeframe by regulation.
–CNA #6 said he attempted to report the allegation anonymously and placed a note under the director of nursing (DON) door a week after the incident occurred. Per the investigative report, the DON denied receiving any notes reporting an abusive situation for any resident.
-The unit LPN who was on duty 2/24/21 was interviewed; The LPN said CNA #6 never reported that he observed CNA #5 physically abusing Resident #238.
–CNA #6 admitted in a second interview that he did not report the abuse to the unit LPN as he initially said he did.
–The investigator asked CNA #6 why did he not report the incident as soon as possible? The witness stated, It was a hectic day.

The above incident was not reported in a timely manner. It was not reported by the witness until 4/9/21 at 3:30 a.m., 47 days after the alleged abuse occurred.
A review of the State Survey Agency abuse allegation reporting database, conducted on 5/12/21, revealed this allegation of abuse was reported on 4/9/21 at 10:32 a.m. The police were not notified of the allegation until 4/9/2021 at 10:05 a.m.