Failure to Implement Abuse Policy Following Resident Verbal Altercation
Penalty
Summary
The facility failed to implement and follow its Abuse, Neglect, and Exploitation policy for two of three residents reviewed for abuse. The policy requires immediate investigation and reporting of all alleged violations, including verbal altercations, to the Administrator and appropriate agencies within specified timeframes. However, a verbal altercation involving two residents was documented in a care plan, but there was no corresponding nursing progress note, abuse investigation, or report to the state agency. The Social Service Director noted the incident in the care plan after it was discussed in a morning meeting, but could not recall which nurse reported the incident, and there was no documentation of the event over the weekend when it occurred. The Administrator in Training, who serves as the facility's Abuse Coordinator, confirmed that she was not made aware of the incident and that no investigation or report was initiated. The lack of communication and documentation by nursing staff and the Social Service Director resulted in the failure to follow the facility's abuse policy, which mandates prompt investigation and reporting of all abuse allegations, including those involving verbal altercations between residents.