Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
A cognitively intact resident (R5), as indicated by a BIMS score of 13, reported that another resident (R9) made a threatening statement to her, saying, "If I had a gun, I'd shoot you." R5 did not report the incident immediately but disclosed it during a therapy session the following day to an occupational therapist (OT K), who stated she would report it to the nursing home administrator (NHA A). Both OT K and a physical therapist (PT L), who was present during the disclosure, confirmed they were not interviewed or asked to provide statements regarding the incident. The facility's investigation was limited to a grievance form that lacked critical details, such as the name of the resident who made the comment, the staff who reported the allegation, and documentation of interviews with staff or other residents. The NHA acknowledged that the incident was considered an allegation of abuse and that the investigation process was initiated. However, the investigation did not include interviews with other staff or residents to determine if similar threats had been made by R9 to others. The only actions taken were speaking with R9, who denied intent and acknowledged the inappropriateness of the comment, and searching R9's room. The NHA admitted that the investigation was not thorough, as required by facility policy and regulatory expectations.