Failure to Investigate Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate an alleged incident of resident-to-resident verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation policy, any suspicion or report of abuse, including verbal altercations, requires an immediate investigation, including identifying and interviewing all involved parties and thorough documentation. However, for an incident involving a verbal altercation and threats of physical harm between two residents, there was no documentation of an abuse investigation, no nursing progress note detailing the event, and no evidence that the required investigative steps were taken. The care plan for one resident was updated to reflect the altercation, but this was based on information shared during a morning meeting and not on a formal investigation. The Social Service Director confirmed that the incident was reported after the weekend, but she did not know which nurse initially reported it, and there was no follow-up with the Abuse Coordinator. The Abuse Coordinator stated she was not made aware of the incident and would have expected to be notified to initiate an investigation. As a result, the facility did not respond appropriately to the alleged violation as required by its own policy.