Failure to Implement Abuse Policy and Investigative Procedures
Penalty
Summary
The facility failed to implement its abuse policy in response to an incident where a resident with a history of physical aggression, related to dementia and other psychiatric diagnoses, physically assaulted another resident. The incident resulted in the victim sustaining a red discharge from the nose and swelling to the head, requiring emergency room evaluation. Documentation showed that the aggressor had a documented history of multiple physical aggression incidents toward both peers and staff, yet the care plan did not reflect new interventions after each event, and the intervention of one-on-one observation had been repeatedly used without documented updates or changes. The facility did not provide evidence of a complete and thorough investigation, as there were no documented witness statements from residents or staff regarding the incident. Additionally, the facility failed to immediately implement one-on-one safety measures as required by policy, and there was no documentation of coordination with QAPI or the implementation of new interventions to prevent recurrence. The administrator confirmed that required documentation and QAPI review were not completed following the incident.