Failure to Thoroughly Investigate and Substantiate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. The incident occurred when one resident, who had a history of behavioral disturbances including aggression and agitation, struck another resident on the back of the head with a PVC pipe while on the smoking patio. Staff were present and intervened immediately, placing the aggressor on one-to-one supervision, but later reduced this to 15-minute checks due to increased agitation. The resident who was struck was assessed and sent to the emergency department for evaluation, where a CT scan was negative for acute injury, and he returned to the facility the same day. Despite multiple staff and resident interviews confirming that the aggressor made contact with the other resident's head using the PVC pipe, the Director of Nursing (DON) reported the incident as an "attempted" contact rather than a substantiated case of abuse. The DON based this decision on the absence of documented injuries and negative CT scan results, despite witness statements and the victim's own report of pain. The facility's documentation lacked a timely skin assessment and did not include adequate documentation of pain status or physician notification at the time of the incident. The facility's policy requires thorough investigation of abuse allegations, including interviews, observations, and documentation of injuries. However, the investigation did not fully comply with these requirements, as evidenced by incomplete documentation and the failure to substantiate the abuse despite corroborating evidence. The deficiency was identified due to the lack of a comprehensive investigation and failure to recognize and report the incident as substantiated abuse.
Plan Of Correction
F610 What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #14 discharged and no longer resides in the facility. Resident #15 was sent to the hospital for further evaluation and returned with no new orders, CT was negative and the resident is back to baseline. Resident #15 was interviewed and has no concerns regarding care. Resident #15 head to toe skin assessed and pain assessed, with no skin alterations and no complaints of pain. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns of abuse, neglect, or exploitation or care concerns. Process of reporting abuse, neglect, and exploitation reviewed with residents at Resident Council by 7/12/2025. Staff interviews conducted to ensure no reported allegations of abuse, neglect or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect, or exploitation allegations with competencies. 2. The administrator and/or designee educated Staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation allegations with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. 4. The Director of Nursing and/or designee educated licensed nurses on resident change in condition to include physician notification of the change in condition, completion of skin and pain assessments to be included for abuse allegation investigation events. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks, then monthly for 3 months. This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is submitted to meet requirements established by state and federal law. F0610