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9/9/2015 Survey Tag 0252 Detail for:
Thursday, September 19, 2019 4:47 AM

Survey Date: 9/9/2015

Regulation Number:0252, level A scope/severity

Regulation Title: Pols & Proceds-Abuse, Neglect Investigation

Regulation Description: 1.104 (5) (l) The facility shall investigate all allegations of abuse and neglect involving residents in accordance with its written policy, which shall include but not be limited to: (i) reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services and to the facility administrator; (ii) a requirement that the facility notify an emergency contact about the allegation within 24 hours of the facility becoming aware of the allegation; (iii) the process for investigating such allegations; (iv) how the facility will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (v) a requirement that the resident shall be protected from potential future abuse and neglect while the investigation is being conducted; (vi) a requirement that if the alleged neglect or abuse is verified, the facility shall take appropriate corrective action; and (vii) a requirement that a report with the investigation findings will be available for review by the Department not later than five working days of the allegation being lodged with a staff member of the facility.

Surveyor Findings:

Based upon record review and interviews, the facility failed to follow its policy for the investigation of abuse and neglect, affecting one former resident (#1). The findings:

On 4/27/15 the department received a complaint that the facility had failed to follow its policy regarding the investigation of abuse and neglect allegations. Specifically, that the facility was made aware of an allegation that former resident #1 had been abused by his/her family member on 2/19/15 and the facility failed to conduct an investigation. It was reported that former resident #1's family member was observed pulling the former resident by his/her nasal cannula in order to force the former resident to move. Additionally, it was reported that the facility staff had expressed concerns that the former resident's family member was known to yell at the former resident in anger and that the facility failed to investigate those concerns.

Review of the Department's occurrence reporting database on 8/28/15 revealed no evidence an occurrence involving former resident #1 was reported by the facility.

The facility's policy titled "Abuse, Neglect & Exploitation Policy," which was provided by the executive director, read in excerpted part: "Instances or allegations of abuse, neglect, or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation and appropriate follow up." "Abuse is also defined as including emotional, physical and sexual abuse and each is defined as follows: (a) Emotional abuse means harassment, threats of punishment, harm or deprivation directed toward the resident; (b) Physical abuse means causing physical harm in a situation other than an accident. This includes behavior, including by not limited to hitting, slapping, kicking or pinching."
"Upon receipt of an allegation of abuse, neglect or exploitation, the Executive Director, or their designee, should conduct a confidential internal investigation of the incident." "The investigation should include interviews with potential witnesses, which may include the alleged perpetrator, the alleged victim, associates, other residents and visitors to the community." "The investigation should be initiated as soon as practicable upon becoming aware of the incident." "The Executive Director or designee should maintain a written record of the investigation. A summary of interviews should be prepared by the Executive Director or designee, including the date, time, name of person being questioned and an impartial report of the facts." "A report with the investigation findings should be made available for review by the Colorado Department of Public Health and Environment no later than five (5) working days of the allegation being communicated to an associate of the community." "The Executive Director or supervisor on duty should notify the resident's physician if there is an allegation of resident abuse, neglect or exploitation. (1) The notification should occur within 24 hours of becoming aware of the allegation. (2) Notification and attempts should be documented in the Resident Log." The policy also included instruction to report the occurrence of the allegation to the department by the next business day.

Review of the former resident #1's record revealed s/he was admitted to the facility on 10/31/14 with diagnoses including dementia. There was no evidence in the former resident's record that an investigation had been conducted regarding an allegation of abuse on 2/19/15 or that the occurrence had been reported to the department. However, a progress note, dated 8/2/15, read that a caregiver "heard (former resident #1's family member) yelling at (former resident #1) to 'shut up' during the night. (Former resident #1's family member) told staff not to check on (the former resident) while (the family member) is there. Staff was informed to do regular checks." A progress note, dated 8/5/15, indicated there was a subsequent care conference in which it was decided that former resident #1 required the services of a 24-hour caregiver (sitter) to manage the former resident's needs and behavior; however, it was decided that #1's family member's "behaviors are not stable under stress and (s/he) should not be the sitter." The note further read that the former resident's family member became upset during the meeting and was told "we (facility staff) would help (him/her) in any way but (s/he) can't talk to staff or (former resident #1) inappropriately when (s/he) becomes upset."

A progress note found in the former resident's record, dated 8/2/15, written by a hospice provider read in excerpted part, "(The executive director) advised that (care staff) stated that (former resident #1's family member) was yelling at (former resident #1) and telling (him/her) to shut up and stop yelling. (The executive director) will review with her supervisor and see if any reporting needs to take place." An additional progress note, dated 8/3/15, written by a hospice staff read in excerpted part, "Patient's (family member) requires more education about dementia." The note indicated the family member experienced, "Extreme feelings of Anger." Under the heading, "Indicate other actual/potential abuse/neglect risk factor" was documented, "History of verbal abuse towards (former resident #1) and staff from (former resident #1's family member)." Two late-entry hospice progress notes dated 8/6/15 for both 8/4 and 8/5/15, read that the decision had been made to have a 24-hour sitter for the former resident and it was agreed that the former resident's family member could be the sitter "with the understanding that there was any issues with (the family member) becoming verbally abusive to staff or (the former resident) that (s/he) would be asked to leave and that (s/he) refused to leave that the police would be called."

The health and wellness director stated that she was aware that the former resident's family member "would yell at (him/her);" to put on his/her oxygen and would say, "your going to kill yourself" (by not wearing the oxygen). The health and wellness director stated that she did not feel the statements were made in anger, but in concern for the former resident's well being.

The executive director stated that she was aware of the allegation made regarding the resident on 2/19/15; however, she was not working at the facility at that time, so she was unable to comment. She states she was aware of the allegation that on 8/2/15 former resident #1's family member had been overheard by staff telling the former resident to "Shut up." She reported that former resident #1's family had a history of being loud with each other, partly due to hearing loss experienced by the former resident, as well as by frustration on the part of the former resident's family member due to the former resident's increasing deficits in cognition due to his/her progressing dementia. She stated that the facility did not see the occurrences as abuse but rather as an opportunity for education and support of the former resident and his/her family. Consequently, the executive director acknowledged she had not followed the facility's policy regarding the investigation of an allegation of abuse.

The district director of clinical services was interviewed on 9/8/15. She stated that she was aware of the former resident and his/her interactions with his/her family member. She stated the administrator of record had informed her on the concern on 2/19/15 and understood that the administrator of record had conducted an investigation. She stated that it was determined former resident #1 had not been abused, and that was why the the occurrence report was not filled with the department; however, acknowledged that a report was required within one business day of the time of the allegation being made, per regulation. The district director of clinical services was asked if staff had overheard a resident being told to "shut up" by a family member, from outside the resident's room, as alleged to have happened on 8/2/15, what her expectation would be for a response by the facility. She stated that she would consider it potential verbal abuse and expect the staff to report the incident and to conduct an investigation.

The administrator of record stated on 9/8/15, that on 2/19/15, she was made aware of an allegation regarding abuse toward former resident #1 by a family member. She stated that she conducted an investigation immediately. She stated that the facility was subsequently visited on an undisclosed date, approximately two to three weeks later, by a local law enforcement representative who was also investigating the allegation. She stated at that time she was informed by the representative that the facility must also file a report of the occurrence with the department. The administrator of record stated she filled an occurrence report with the department online the day she learned of the requirement from the law enforcement representative. When she was informed by the investigator that there was no record of an occurrence report being filed, she stated that she had been curious why there had been no follow up by the department; however, she conceded she had not followed up to see if the report had been successfully transmitted. Additionally, the administrator of record was asked if she were aware of the occurrence on 8/2/15 as documented in the facility progress notes and hospice progress notes regarding the verbal abuse of former resident #1. She stated she was not aware of that occurrence. When asked if she had been made aware, what her actions would have been. She states she would have asked the former resident's family member to leave the facility until an investigation was conducted.

The administrator of record was asked if she had written a report to document the investigation of the 2/19/15 occurrence. She stated she had kept the report in her files. She was requested to provide a copy of the report to the department by the end of business on 9/8/15, which was approximately five hours after the interview. As of 9/11/15, the report had not been received by the department. During a follow up interview, the administrator of record stated that she had sent the report to the facility's legal department before sending it to the department and would request that a copy be sent as soon as possible. The department received a faxed copy of an investigation report at 11:30 a.m. on 9/12/15, which was not within five days of the allegation being made.

In summary, the investigation revealed that facility staff had information of at least two occurrences of alleged abuse toward former resident #1. Neither occurrence was reported to the department as required in the facility's policy and in regulation. Additionally, the facility failed to follow its policy and investigate the allegation that the former resident's family member had been verbally abusive to him/her. Lastly, the facility failed to make the investigation report available to the department within five days of the 2/19/15 allegation being made.




Facility Plan of Correction:

P252 Abuse and Neglect
The management team will be re-trained on the occurrence reporting process, state reportables and the Abuse, Neglect and Exploitation policy on Nov 3, 2015 by the District Director of Operations and the District Director Clinical Services. ED, HWD or designee will review shift reports to monitor for incidents of suspected abuse, neglect or exploitation and ensure the investigation is initiated, and reported to state and local law enforcement within 24 hours. The investigation findings will be completed no later than the 5 workings days and the final report will be available for surveyors review if requested. DDO or DDCS to monitor for compliance during routine site visits.


(1.How was the in-service with the management team documented?)

An in-service/training sign-in sheet will be provided to document that associates attended training, as well as a copy of the Abuse and Neglect Policy attached to the sign-in sheet.

(2.How often will the monitoring during site visits be occurring and how will that monitoring be documented?)

Community site visits will be conducted bi-annually by the DDCS or DDO, unless it is needed sooner. The visit will be documented on the site visit form and legal documentation in chart.

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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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