HAMILTON, MO- HILL CREST MANOR

Per Hamilton Missouri Police Department Facebook Page: On 10/04/2023, at 3:07 am, officers responded to a business at the 800 block of S. Colby Street, for a report of elder abuse. As a result of the investigation, three employees were arrested and held at the Caldwell County Detention Center.

-A member of N.H.A.A. called and spoke with an officer of the Hamilton Police Department, who confirmed the information above and said the individuals had been released on bond. 

Based on interview and record review, the facility failed report an allegation of staff to resident abuse to the Department of Health and Senior Services (DHSS and law enforcement (LE), when Resident #2 told the Director of Nursing (DON) Certified Medication Technician (CMT) A caused a bruise to Resident #1’s right forearm in an attempt to take a magazine from him/her, The facility also failed to report an allegation of verbal abuse towards Resident #2, when CMT A called the resident a needy little bitch, to DHSS. This affected two of six residents sampled. The facility census was 49.

Review of the undated Abuse and Neglect policy showed: The facility staff were to report allegations of abuse to DHSS and LE within the federal required time frames.
1. Review of the facility investigation, dated 2/5/23, showed:
– The investigation was completed and documented by the DON.
– Resident #1 told the DON he/she was in a verbal argument with Resident #3 over a magazine. He/she had possession of the magazine.
– CMT A entered his/her room, tried to take the magazine from him/her. He/she hid the magazine behind his/her back as CMT A reached for it he/she hit Resident #1’s arm and left a large purple bruise.
– The DON identified a large purple bruise with a hematoma (swollen area caused by collected blood) to the resident’s right forearm.
– Resident #3 told the DON Resident #1 said he/she had his/her magazine. The two resident’s argued and Resident #3 gave the magazine to Resident #1.
– CMT A entered the room to settle things.
-The DON documented CMT A entered resident #1’s room after he/she heard Resident #1 and #3 arguing. He/she asked for the magazine, Resident #1 would not give it to him/her.
– He/she squatted in front of the resident, the resident raised his/her fist and put his/her foot at CMT A’s groin.
– CMT A said he/she did grab Resident #1’s arm and pushed the wheelchair away.
During an interview on 3/23/23 at 11:04 A.M., Resident #2 said:

– He/she was in the shower, that was across the hall from Resident #1’s room, with Nurse Aide (NA) A on 2/4/23 and heard the resident yelling.
– CMT A entered the shower room and asked him/her what was going on, CMT A thought the noise came from the shower room.
– CMT A discovered the shouting came from across the hall.
– A few minutes later CMT A entered the shower room again and reported he/she took care of the situation.
– The morning of 2/5/23, Resident #1 pulled up her shirt sleeve and showed Resident #2 a large purple bruise to his/her forearm. Resident #1 reported to him/her that CMT A grabbed his/her arm to take a magazine away from him/her.
-Resident #2 reported the incident to the Director of Nursing (DON) on 2/5/23.

Observation of a photo obtained on 2/5/23 by Resident #2 showed Resident #1’s right forearm with an orange size dark purple bruise above the wrist on top of the arm. A second lighter purple bruise, the size of an orange can be seen directly above the first bruise. Redness to the area can be seen connecting the two bruises.

During an interview on 3/23/23 at 3:24 P.M. Resident #3 said:
– He/she and Resident #1 was in the door way of Resident #1’s room, Resident #1 was in his/her room and Resident #3 was in the hallway. Both residents were in their wheelchairs.
– The resident’s argued over a magazine Resident #3 had possession of. He/she then gave the magazine to Resident #1 to stop the argument.
– CMT A stepped in between the resident’s, Resident #1 held the magazine behind his/her back.
– CMT grabbed the Resident #1’s arm, took the magazine away from him/her. CMT A bruised the resident’s arm real bad.
– He/she did not see the resident make a fist or lift his/her feet from the ground.

During an interview on 3/29/23 at 9:32 A.M. CMT A said:
-He/she was standing at the medication cart at the south nurse’s desk and heard Resident #1 and Resident #3 arguing.
– He/she separated the residents and discovered they were arguing over a magazine that Resident #1 had possession of.
– He/she squatted in front of Resident #1, who then balled his/her fist at CMT A

– CMT A raised his/her left arm to block the resident. He/she did not recall if he/she made contact with the resident.
– Resident #1 said he/she would not give the magazine to CMT A. CMT A grabbed the magazine form the resident.
– He/she should not have taken the magazine from the resident.
– He/she should have walked away and reproached the resident later in the day.

During an interview on 3/29/23 at 12:09 P.M. the DON said:
– She conducted the abuse investigation as she always had by speaking to the two residents involved and CMT A.
– She felt like Resident #1’s bruise occurred during the incident, but did not look like a hand print.

The bruise was dark purple, long and thin four centimeters long and 2.5 centimeters wide.
– CMT A denied touching the resident.
– She did not report the incident to DHSS or LE, because there was no major injury.
– She should have reported the incident to DHSS and LE.

During an interview on 3/28/23 at 12:47 P.M., the Administrator said:
– She identified herself as the Abuse coordinator.
– She did not report the incident to DHSS and LE and should have.

During an interview on 3/23/23 at 4:00 P.M., the Corporate nurse said:
– The Administrator or DON should have reported the allegation to DHSS and LE.
2. Review of Resident #2’s Admission MDS, dated [DATE], showed:
– He/she had a BIMS score of 15, indicating no cognitive impairment.
– Diagnoses included: Heart Failure and anxiety.
– He/she required the assistance of one staff to transfer, get dressed and use the toilet.
During an interview on 3/23/23 at 11:04 A.M., resident said:
– One evening in early February 2023, CMT A placed his/her evening medications on the night stand. The resident was asleep and when she awakened later, the resident found pills lying on his/her chest. – The resident turned his/her light on, CMT A entered his/her room.
– CMT A told the resident you know, you are a needy little bitch.
– This comment made the resident feel angry and he/she felt abused.
– He/she reported the incident to his/her Family Member.

During an interview on 3/23/23 at 3:49 P.M. the Family member said:
– The resident called him/her and was upset and mad because CMT A called him/her a needy little bitch one evening in early February 2023.
– He/she then called the facility and spoke with the DON and reported what the resident told him/her. During an interview on 3/29/23 at 9:32 A.M. CMT A said:
– He/she called Resident # 2 a needy little bitch after he/she had turned the call light on during the evening, but could not recall the date.
– He/she said he/she was joking with the resident and did not realize there was a problem until the next morning when the DON talked with him/her and stated the resident made a complaint about him/her calling the resident a needy little bitch.
– The DON verbally told him/her that was an inappropriate thing to say and not to do it again.

During an interview on 3/29/23 at 12:09 P.M., the DON said:
– She overheard CMT A talking about calling the resident a needy little bitch to someone. The DON could not recall who it was. CMT A told the DON the resident kept telling him/her that he/she was being a needy little bitch and CMT A called him/her that as he/she left the resident’s room.
– She did not recall when she became aware of the incident and did not document anything about the incident.
– CMT A admitted he/she called the resident a needy little bitch as he/she was exiting the resident’s room in a joking manner.
– She told CMT A he/she was not allowed to call resident’s names.

During an interview on 3/29/23 at 2:00 P.M. PCP B said:
– He would have expected the facility staff to notify DHSS of the incident for Resident #2.
3. During an interview on 3/28/23 at 12:47 P.M. the Administrator said:
– The allegations should have been reported to DHSS.

During an interview on 3/28/23 at 11:45 A.M. The Director of Regional Consulting said:
– He/she would have expected the incidents to be reported to DHSS and LE.