Failure to Thoroughly Investigate Resident Altercation Involving Weapon
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents in the smoking patio, resulting in one resident injuring the other with a knife. Both residents had significant psychiatric and physical diagnoses, including dementia, schizophrenia, depression, anxiety disorder, and hemiplegia. The incident occurred when both residents, each in a wheelchair, engaged in a verbal argument that escalated to physical contact, culminating in one resident using a knife to injure the other. Video surveillance confirmed the sequence of events, and it was noted that no staff were present in the smoking patio during the altercation. The investigation into the incident was incomplete. The administrator acknowledged that she did not request surveillance footage from all available cameras to track the residents' movements after the altercation. Additionally, the location of the knife used in the incident remained unknown, as searches of the resident, the smoking patio, common areas, and the resident's room did not yield the weapon. The administrator admitted that the investigation was not thorough, and the facility's policy required all allegations to be thoroughly investigated, with supporting documents and evidence provided to the individual in charge of the investigation. The facility's failure to conduct a comprehensive investigation and to account for the weapon used in the altercation placed residents at risk for further abuse. The lack of staff supervision in the smoking patio at the time of the incident was also confirmed by video review. The administrator's statements and the documentation reviewed indicated that the facility did not meet the regulatory requirements for investigating and preventing further potential abuse during the investigation process.
Plan Of Correction
F 610 Maclay Healthcare Center makes every effort to comply with the State and Federal regulations. Nothing in this plan of correction is an admission otherwise. Maclay Healthcare Center submitted this plan of correction to comply with the State and Federal regulations and does not waive any objection obtained. This plan of correction is our credible allegation of compliance for deficiency noted findings of the California Department of Public Health during the Facility reported incidents survey completed on 3/22/25.