Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. According to facility policy, investigations of resident-to-resident abuse require interviews with cognitive residents and witnesses, as well as head-to-toe assessments for non-cognitive residents if necessary. An incident report documented that the resident was punched in the face by another resident, resulting in a red discharge from the nose, swelling to the head, and a subsequent emergency room visit. Despite these events, there were no documented witness statements from staff or other residents regarding the incident, and the administrator confirmed that a thorough investigation was not completed.