Failure to Notify Family and Physician of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify both the family and physician of an incident involving resident-to-resident abuse. Specifically, a resident with severe cognitive impairment and a history of physical and verbal behaviors was documented as having kicked another resident in the face. Progress notes indicated that the nurse observed the incident and addressed the behavior with the resident, but there was no documentation that the physician or the family of either resident involved were informed of the event. The facility's risk management policy requires that such incidents be reported to the appropriate parties, including the physician and family, and that a progress note be entered in the resident's chart. Both residents involved had severe cognitive impairment, with one resident also diagnosed with Alzheimer's disease, Down Syndrome, and moderate intellectual disabilities, and was on hospice care. Despite these vulnerabilities, the clinical records for both residents lacked evidence that their families or physicians were notified about the incident. Staff interviews confirmed that the family should have been informed, but this did not occur, constituting a failure to follow facility policy and ensure appropriate communication after a significant event.