Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents. According to the facility's policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying and interviewing all involved parties and witnesses, and documenting the process. In this incident, one resident with a history of combative behavior threw a cup of coffee in the direction of another resident during a dining room activity. The resident who threw the coffee was immediately removed and placed under one-to-one supervision, and both residents were assessed for harm. The investigation conducted by the facility did not include all relevant witness interviews or documentation. Specifically, the investigation failed to document that the coffee was thrown directly at the other resident, despite statements from staff indicating this occurred. Key witnesses, including an LPN and the pulmonary program coordinator who observed the incident, were not interviewed or their statements were not included in the investigation file. Additionally, staff who were interviewed as part of the investigation were not present during the incident, and the investigation did not capture all available information about the event. The residents involved had significant cognitive impairments and required supervision for activities of daily living. The resident who was the alleged victim was monitored after the incident and showed no signs of pain or discomfort. The facility's documentation and investigation process did not align with its own abuse policy, as it did not ensure all relevant staff were interviewed or that all evidence was collected and documented. The nursing home administrator acknowledged that the investigation was incomplete and that the incident was not clearly identified as abuse versus a behavioral issue.