Arbors at Milford

Based on medical record review, staff interview, facility investigation review, and facility policy review, the facility failed to implement their abuse policy by timely reporting and thoroughly investigating an allegation of staff to resident verbal abuse. This affected one (Resident #15) of three residents reviewed for abuse. The census was 26.

Findings include:

Review of the medical record for Resident #15 revealed Resident #15 was admitted to the facility on 08/18/22. Resident #15's diagnoses included chronic obstructive pulmonary disease, major depressive disorder, morbid obesity, hypertension, hyperlipidemia, hypocalcemia, post-traumatic stress disorder, neuropathy, and type two diabetes.

Review of Resident #15's Assisted Living Assessment, dated 11/07/23, revealed Resident #15 was cognitively intact.

Review of Resident #15's medical record revealed no documentation related to an allegation of verbal abuse or investigation into an allegation of verbal abuse.

Review of facility abuse incident investigation, initiation date of 07/31/23, revealed 25 total resident interviews. There were no staff interviews completed. There was no documentation of a physical/mental evaluation completed after findings out about the allegation. There was no documented attempt to contact the nurse who allegedly verbally abused Resident #15. Finally, there was documented summary/findings of what the facility found to be the outcome of an investigation.

Interview with Consultant Investigator #120 on 12/01/23 at 12:31 P.M. revealed she did a remote investigation and found that the facility was not in compliance with preventing abuse. She indicated she completed her investigation on 08/22/23. She revealed she interviewed Resident #15, but no one else. She stated Resident #15 was credible and had a strong recollection of the events.

Interview with the Administrator on 12/01/23 at 1:15 P.M. revealed she found out about an allegation of staff to resident verbal abuse involving Resident #15 on 07/31/23, when Consultant Investigator #120 contacted her. She stated she interviewed residents about the alleged staff to resident verbal abuse involving Resident #15 however she did not interview any staff. The Administrator stated she accepted the findings of the consultant investigator and did abuse training with all the staff. She confirmed their policy stated they were to interview all possible witnesses. She confirmed there was one aide on the assisted living side of the building as well as other staff on the other side of the building at the time of the alleged incident. She confirmed none of the other staff who were in the building at the time of the alleged incident were interviewed. She revealed they did not develop a findings as a result of their investigation and just accepted the findings of Consultant Investigator #120. vThe Administrator confirmed the facility did not notify the state health agency after finding out about the allegation of staff to resident verbal abuse involving Resident #15.

Interview with Resident #15 on 12/01/23 at 1:24 P.M. revealed there was an incident of alleged verbal abuse in March 2023. Resident #15 indicated the incident occurred on a Sunday, but could not remember the exact day. He stated there were two other female residents in the dining room with him when the female nurse came in and belittled him. Resident #15 indicated the nurse left the facility early near the end of her shift. Resident #15 indicated he asked the aide where the nurse was and she stated the nurse had gone home. Resident #15 indicated shortly after asking that, the nurse was called back into the facility and yelled at him for not minding his own business. Resident #15 did not remember the names of the other two residents who were present at the time of the alleged incident. Resident #15 indicated the nurse no longer worked at the facility. Resident #15 indicated he did not report the incident to anyone at the facility when it occurred.

Review of facility Abuse, Neglect, and Exploitation policy, dated 10/24/22, revealed the facility will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Mental abuse was defined, but limited to, humiliation, harassment, threats of punishment or deprivation. The facility will have written procedures that include: reporting all alleged violations to the administrator, state agency, adult protective services and to all other required agencies. Immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse. Procedures for an investigation include identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, all witnesses, and others who might have knowledge of the allegations. Please complete and thoroughly document the investigation.

Based on review of personnel files and staff interview, the facility failed to ensure Assisted Living Hospitality Aide (ALHA) completed the required first aid training. This affected two (#10 and #12) out of three ALHA files reviewed and had the potential to affect all 25 residents residing in the facility. The facility census was 25.

Findings include:

Review of personnel files revealed two (#10 and #12) of three ALHA's revealed the staff did not have evidence of completion of first aid training within 60 days of hire. ALHA #10 had a hire date of 04/29/20, and ALHA #12 had a hire date of 08/19/22.

Interview on 05/04/23 at 10:27 A.M. with the Administrator confirmed no documentation of first aid training for ALHA #10 and #12 within 60 days of hire.