Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and implement interventions in response to multiple incidents of resident-to-resident abuse involving a resident with severe cognitive impairment and a history of physical and verbal aggression. Clinical record review showed that this resident exhibited repeated aggressive behaviors, including kicking, hitting, and verbal abuse directed at another resident and staff over several months. Despite documentation of these behaviors in progress notes, there were no care plan interventions addressing the resident's abusive behaviors toward others until a focused area and interventions were added months after the initial incidents. Interviews with facility leadership confirmed that no actions were taken to address or investigate the incidents prior to the addition of care plan interventions. The administrator stated that she would have investigated the abuse if she had been made aware of it, and the DON acknowledged that staff did not report the incidents as required. Facility policy directs that any observed or suspected abuse should be investigated by management, but this protocol was not followed in these cases.