Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving a female resident with multiple medical and behavioral diagnoses, including COPD, anxiety, PTSD, and insomnia. The resident reported being physically assaulted by another male resident, who also has a history of violent and psychotic behavior, while in the elevator. The incident was witnessed by two LPNs, and both a psychotherapist and a physician's assistant were informed. Despite the allegation, the resident stated that she was never interviewed by the administrator or the director of nursing, the police were not contacted, and no incident report was filed at the time. The administrator confirmed being notified of the allegation by an LPN, who reported that the resident was sobbing and claimed her dentures were broken. The administrator noted that the resident had no visible injuries and would not speak further about the incident. The initial facility-reported incident was not filed until eight days after the alleged event, and no documentation related to the investigation was provided for the period prior to the report. The facility's abuse policy requires thorough investigation of all alleged violations, but there was no evidence that this was done in this case.