Failure to Investigate Resident Altercation and Rule Out Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an altercation between two residents, one of whom had a history of a right humerus fracture, type 2 diabetes, insomnia, and chronic pain syndrome, and was able to communicate needs. The incident occurred when one resident, using an electric scooter, bumped another resident's chair, causing it to spin. Following the event, staff observed the affected resident with their head down and moved them to another area to relax. The incident report indicated that the plan was to remove the electric scooter from the resident who caused the incident. However, a review of records showed that no investigation was conducted or documented regarding the altercation, and no interventions were recorded for the resident operating the scooter after the occurrence. The facility's policy required identification and interviews of all involved parties and thorough documentation to determine if abuse had occurred. During an interview, the DON stated that investigations are typically conducted for such incidents but was unsure why it did not happen in this case, attributing the lapse to a new staff member who needed more training.