Failure to Implement Abuse Prevention Policy and Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident with severe cognitive impairment who exhibited worsening verbal and physical behaviors. The resident was involved in multiple resident-to-resident altercations, including both physical and verbal aggression, over several months. Despite the facility's policy requiring identification, reporting, and investigation of potential abuse, many incidents were not properly documented, investigated, or reported to the State Survey Agency as required. In several cases, incident reports contained only a single statement with no additional staff or resident interviews, and there was no documentation that abuse or neglect was ruled out. The resident's care plan was not consistently updated or revised following each altercation, and interventions were not re-evaluated for effectiveness or modified to prevent recurrence. Although some interventions, such as 15-minute safety checks and providing items for the resident to rummage through, were implemented, there was no evidence that these were reviewed or adjusted after subsequent incidents. Additionally, several altercations were not included in the facility's incident tracking log, nor were they reported or investigated as required by policy. The facility's QAPI committee minutes lacked documentation showing that allegations of abuse, investigations, and corrective actions were tracked or analyzed for patterns or systemic issues. Interviews with staff revealed a lack of consistent understanding and application of the abuse policy, particularly regarding verbal altercations. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, nor had it addressed all incidents as potential abuse according to policy.