**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to have an effective system to ensure their abuse policy was implemented for three (3) of six (6) sampled residents, Resident #1, #2, and #4.

Staff interviews and record review revealed on 11/15/17, Certified Nursing Assistant (CNA) #8 allegedly placed tape on Resident #4’s mouth to keep the resident from yelling out. Registered Nurse (RN) #2 recalled an allegation of abuse related to the Resident #4 but could not recall if she notified Director of Nursing (DON) #1 of the incident. Staff failed to follow the facility’s abuse policy as Administrator #1 was not made aware of the incident, an investigation was not completed at the time of the incident, and state agencies were not notified.

Interviews with staff revealed in (MONTH) (YEAR), CNA #4 and #5 overheard CNA #8 call Resident #2 a [***] and threaten the resident, and witnessed CNA #8 forcibly push a washcloth between the resident’s legs when providing care. CNA #4 and #5 reported the incident to RN #2 and she sent CNA #8 home and notified DON #1 of the incident via text message. In addition, CNA #4 and #5 submitted written statements to the DON. However, staff did not implement the abuse policy as Administrator #1 was not made aware of the abuse allegation, the allegation was not investigated, and the allegation was not reported to state agencies.

Interview and record review revealed on 09/01/18, while CNA #1 and #2 provided care to Resident #1, the resident called out CNA #8’s name and said the CNA was bad and hurt him/her as he/she motioned to his/her pubic area. The CNAs reported the incident to the Assistant Director of Nursing (ADON) by telephone; however, the ADON stated the conversation was about the resident possibly having a Urinary Tract Infection and the CNAs never voiced concerns that CNA #8 possibly abused the resident. Staff did not implement the abuse policy as Administrator #3 was not made aware of the incident, an investigation did not occur at the time of the incident, and the incident was not reported to state agencies.

In addition, interview and record review revealed Administrator #2 and Administrator #3 were knowledgeable of inappropriate sexual behaviors of CNA #8 towards staff; however, residents were not assessed or interviewed to investigate possible resident abuse. The CNA was allowed back to work on 05/29/18, after a five (5) day suspension.

The facility’s failure to have an effective system in place to ensure the abuse policy was implemented has caused or is likely to cause serious injury, harm, impairment, or death to residents.

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.