Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an alleged incident of abuse involving two residents. According to the report, a CNA witnessed one resident, who has a history of behavioral issues and severely impaired cognition, physically contact another resident on the right arm. The CNA immediately reported the incident to an LVN, who assessed the alleged victim for injuries and found none. The LVN then reported the incident to the ADON and Administrator. Despite this, no incident report or skin assessment was completed, and the event was not reported to the state agency as required by facility policy. The resident who was allegedly struck has a diagnosis of dementia/Alzheimer's and impaired cognitive function, but was documented as able to make herself understood and understand others. The resident who allegedly struck her has paranoid schizophrenia, a BIMS score indicating severe cognitive impairment, and a documented history of behavioral symptoms directed toward others. The care plans for both residents included interventions for their respective cognitive and behavioral issues, but there is no documentation that these interventions were reviewed or updated in response to the incident. Interviews with facility staff revealed confusion and lack of follow-through regarding the reporting and investigation process. The Administrator and ADON did not interview the residents involved or the CNA who witnessed the incident, and the Administrator stated he did not report the incident to the state agency because there was no injury. The ADON stated she expected an incident report and skin assessment to be completed, but this was not done. The facility's Abuse Prohibition Policy requires thorough investigation and timely reporting of all allegations, which was not followed in this case.