GRAND JUNCTION, CO- MESA MANOR CENTER

Based on interviews and record review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for five (#1, #2, #3, #4 and #5) out of 20 sample residents.

Specifically, the facility failed to:

–Conduct thorough investigations on five separate complaints/allegations of inappropriate touching, kissing, hugging, tickling, verbal gestures, unwanted care and intrusive behavior by certified nurse aide (CNA) #1 between 12/31/22 and 3/15/23; and,
-Provide a clear corrective action and a monitoring/supervision plan to protect all residents.

According to the facility investigative report dated 12/31/22, the resident reported to her floor nurse that CNA #1 inappropriately touched her during care. The report revealed that a mandatory police report had been filed and the family, the ombudsman, the physician and adult protection services (APS) had been notified. The resident was kept safe, the CNA was immediately removed from the floor and the manager on duty immediately placed the alleged assailant on administrative leave. An interview documented by the director of social services (DSS) on 1/3/23 revealed Resident #1 stated that CNA #1 caressed her outer/top area of her leg while performing care and said it was weird so she reported it to the nurse. The resident stated CNA #1 kissed her left cheek and said I love you. The resident stated CNA #1 had done this before, but she had not reported it.

-The facility failed to interview LPN #1 directly about the incident after it was revealed she was the staff nurse to whom Resident #1 reported on the night of the allegation, 12/31/23.

-The facility failed to interview family members for other residents or representatives for Resident #1.
-The facility failed to provide clear instructions on care limitations to CNA #1 and how care would be monitored. Specifically, the facility failed to document CNA #1 was not to provide care for Resident #1.

A facility investigative report began with an email message which revealed the ADON was notified on 2/18/23, a CNA reported Resident #2 reported to her that CNA #1 kissed her hand and said she thought he was gross. The ADON requested the CNA write a report and slip it under the desk of the NHA. The email message showed the NHA did not receive the CNA’s report.

-The facility failed to conduct and document an interview with CNA #1, the subject of the resident’s allegation.

-The facility failed to show evidence that corrective action was taken to protect Resident #2 and honor her choice to not have CNA #1 care for her.

A statement dated 3/15/23 at 7:05 a.m. from the medical records manager (MRM) stated she witnessed CNA #1 cleaning Resident #3 and the resident said stop multiple times but CNA #1 continued. She asked the resident if he wanted CNA #1 to stop and confirmed that he wanted him to stop. A statement dated 3/15/23 from the NHA documented she received a report that CNA #1 was observed washing Resident #3 to get him ready for an appointment and the resident told CNA #1 to stop.

-The facility failed to show evidence of an interview with the MRM who witnessed and reported the incident.
-The facility failed to interview CNA #1 regarding the incident.
-The facility failed to provide evidence that corrective action was taken to protect Resident #3 from further distress.

In a written statement dated 3/14/23, the business office manager (BOM) documented she saw CNA #1 conversing with Resident #4 in the hall. CNA #1 asked Resident #4 why does it hurt to smile? CNA #1 proceeded to tickle and poke at the resident’s neck and ear area. The resident tried to push CNA #1 away, but could not reach him and tried to get out of his wheelchair.

A statement dated 3/14/23 by the NHA documented a staff member reported CNA #1 was observed touching Resident #4 around the neck and shoulder area which appeared as a tickle or poke then the resident swatted the CNA’s hand and tried to stand up from the wheelchair. Administration met with CNA #1. CNA #1 stated I don’t tickle anyone, and stated he did pat the resident on the shoulder when talking to him.

The BOM was interviewed on 5/16/23 at 2:40 p.m. regarding the incident. She said she knew CNA #1 was trying to joke with Resident #4 by asking him if his smile was broken and then he started tickling him on the neck and that’s when it really clicked, and (Resident #4) was trying to bat him away, and I told (CNA #1) ‘he’s had enough.’

CNA #1 was interviewed 5/17/23 at 8:30 a.m. He stated he had tickled Resident #4’s foot one time and was told by the DON not to do that because the resident had mood swings. He denied poking or speaking disrespectfully to the resident at any other time.

-The facility failed to show evidence of an interview with the BOM who witnessed the incident.
-The facility failed to interview other staff or witnesses in the area at the time of the incident.
-The facility failed to provide evidence that corrective action was taken to protect Resident #4 from further distress.

Resident #5 was interviewed on 5/16/23 at 2:57 p.m. She stated, I am very uncomfortable with (CNA #1) and his general attitude. It is hard to be in his presence. He’s intrusive. I get angry and frustrated when he comes into my room to help with my care.

-The facility failed to initiate interviews with staff present at the time the resident reported feeling
uncomfortable.
-The facility failed to contact the resident’s representative for an interview.
-The facility failed to provide evidence corrective action was taken and residents were protected.

The DON said CNA #1 would not return to work due to the repeated abuse allegations, his apparent lack of understanding regarding the nature of the allegations and the facility’s inability to continue providing care in pairs while CNA #1 was on duty due to staffing.