Failure to Investigate Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, as required by its own policies and regulatory standards. Progress notes documented that one resident, who had dementia with psychosis and moderate cognitive impairment, exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with a history of stroke and no cognitive impairment, after the first resident took the other's hat, leading to an argument that staff had to intervene to stop. Despite these documented incidents, the facility was unable to provide evidence of any investigations into the alleged abuse or altercations. The Director of Nursing (DON) acknowledged awareness of some of the incidents but could not provide details about the specific behaviors, the individuals involved, or any investigative actions taken. There was also no documentation to show that the incidents were reviewed or that appropriate actions were implemented in response to the behaviors. The facility's policies require that all allegations of abuse and resident-to-resident altercations be promptly reported, thoroughly investigated, and documented, with findings reported to appropriate leadership. However, the lack of investigation records and incomplete knowledge of the incidents by facility leadership demonstrate that these procedures were not followed for the incidents in question.