Failure to Thoroughly Investigate Resident Altercation and Determine Root Cause
Penalty
Summary
The facility failed to conduct a thorough investigation and determine the root cause of an altercation between two residents, resulting in a deficiency related to abuse prevention and response. The incident involved one resident who was agitated in a common area and another resident who was exiting the elevator. During the encounter, the agitated resident made contact with the other resident's forehead, causing the latter to fall and sustain injuries, including redness and a bruise on the forehead. The injured resident reported being repeatedly punched in the head and expressed that the incident was not accidental, while staff and documentation provided conflicting accounts, with some suggesting the event was accidental. The facility's investigation was insufficient, as it did not reconcile the differing accounts from the residents and staff, nor did it adequately address the injured resident's statements that the altercation was intentional and involved multiple blows. The facility's administrator concluded the incident was accidental without substantiating this determination through a comprehensive review of all available evidence, including interviews and medical records. The facility's abuse prevention policy requires a thorough investigation of any alleged abuse, including interviews with all involved parties and review of pertinent documentation, which was not fully executed in this case. Additionally, the facility's documentation and staff interviews revealed inconsistencies regarding the nature and severity of the incident. The injured resident was alert and oriented, with an intact cognitive status, and clearly described the event as intentional. Despite this, the facility's final report characterized the incident as an accident, which was incongruent with the findings and the resident's account. The failure to conduct a complete and objective investigation had the potential to affect all residents in the facility.