Failure to Investigate Resident-Staff Altercation for Possible Abuse
Penalty
Summary
The facility failed to investigate an incident involving a verbal argument and physical altercation between a resident and the Maintenance Director to rule out abuse. The incident began when the resident and the Maintenance Director had a confrontation in the elevator, which escalated to physical contact, with both parties reportedly swinging at each other and the Maintenance Director sustaining a contusion and muscle injury. The resident reported feeling harassed and being called derogatory names, while the Maintenance Director described attempts to deescalate the situation and reported the injury to human resources and the administrator. Despite the altercation and the resident's allegations, the administrator did not conduct an investigation into the incident, did not interview the resident, and did not consider the possibility of abuse, relying solely on staff accounts that the resident was the aggressor. The facility's policy requires that all incidents, whether or not abuse is alleged or suspected, be reviewed, investigated, and documented. However, the administrator, who also serves as the abuse coordinator, stated that incidents involving residents being aggressive toward staff are not reported to public health and are not investigated as abuse. The administrator did not follow the facility's investigation procedures, which include interviewing all parties involved, including the resident. As a result, the incident was not properly investigated to rule out abuse, contrary to facility policy and regulatory requirements.