Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation Policy, an immediate and comprehensive investigation is required when abuse is suspected or reported. However, the incident narrative provided was undated and incomplete, lacking critical details such as the time of the incident, the date and time of required notifications, and documentation of which staff and residents were interviewed, the results of those interviews, and the date and time of those interviews. The investigation was not documented chronologically, and there was no evidence of subsequent monitoring or assessment of the residents' psychosocial outcomes following the incident. The incident involved one resident physically hitting another in the back and verbally threatening them, as witnessed by a CNA. Nursing staff separated the residents and assessed the victim for injury. Despite these actions, the facility's documentation did not meet policy requirements for a thorough investigation, including notification of the attending physician and the resident's family or legal representative, as well as ongoing monitoring and documentation of the residents' conditions after the event.