Failure to Investigate and Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident altercation involving two residents. On two separate occasions, one resident with a history of bipolar disorder and schizophrenia, and another resident with hemiplegia, aphasia, and major depressive disorder, were involved in verbal and physical altercations. Staff witnessed these incidents, including one where a resident became physically aggressive and threatened further altercations, and another where both residents argued about personal space. Despite staff witnessing and documenting the incidents in progress notes, there was no evidence that a formal investigation was conducted or documented as required by the facility's abuse policy. The Director of Nursing (DON) acknowledged the altercations and stated that the residents were separated, but could not provide any documentation of an investigation or its outcome. Additionally, the incidents were not reported to the State Agency as mandated by facility policy. The facility's policies require that all reports of resident abuse, including resident-to-resident altercations, be thoroughly investigated, documented, and reported to appropriate authorities. However, the lack of investigation documentation and failure to report the incidents to the State Agency constituted a failure to follow these procedures, resulting in a deficiency.