Failure to Implement Abuse and Change of Condition Policies After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse and change of condition policies for two residents following an allegation of resident-to-resident abuse. Specifically, after one resident reported being physically assaulted by her roommate, staff did not notify the residents' family representatives or physicians, did not complete Special Incident Reports (SIR), and did not document Interdisciplinary Team (IDT) notes in the residents' charts. The investigation summary and interviews confirmed that these required notifications and documentation were not completed, and there was no evidence of care plans being initiated for either resident involved in the incident. Staff interviews revealed that licensed staff were expected to notify family representatives and physicians, complete SIRs, and initiate care plans after abuse allegations, but these actions were not taken. The facility's policies required immediate reporting and documentation of such incidents, as well as interdisciplinary review and care plan updates following significant changes in a resident's condition. Despite these requirements, the records showed no documentation of the necessary notifications, incident reports, or care plan revisions related to the abuse allegation.