Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an alleged resident-to-resident physical altercation involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. Medical record reviews indicated that both residents were competent and cognitively intact at the time of the incident. Documentation from a change in condition note described the event as an accidental graze by one resident's hand, but staff interviews revealed conflicting accounts, with one CNA stating that the incident was reported as a hit and a retaliatory action. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the incident. Interviews with staff present during the incident, including CNAs and LVNs, confirmed that the event was known and reported to nursing leadership. However, the Director of Nursing (DON) was unable to provide documentation or evidence of an investigation, such as interviews with involved staff or a formal review of the incident. The facility's policy required all allegations of abuse to be thoroughly investigated and reported, but this process was not followed in this case, resulting in a deficiency for failure to investigate and document the alleged abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/25/25 upon notification of the alleged violation, the facility immediately initiated an investigation following the facility's Abuse Policy and Investigation Protocol. The involved resident (Resident 1) was assessed with no injuries noted, and protective measures were implemented during the immediate period of the alleged incident. The responsible parties (resident 1 is self-responsible, and responsible party for resident 2) were notified. The alleged perpetrator (resident 2) was discharged to a different facility on 6/17/25. On 6/25/26 and 6/26/25, the Administrator, DON, Medical Records Director, and Social Services reviewed current residents to ensure no other unresolved allegations were pending investigation. No other residents were identified as affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A review of the incident/accident logs, grievance logs, and nursing notes was conducted on 6/25/25 by the Administrator (Abuse Coordinator), DON, Medical Records Director, and Social Services to ensure that any previous allegations had been fully investigated, resolved, and documented appropriately. No additional concerns requiring investigation were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON conducted in-service training to staff on the facility's Abuse Prevention, Reporting, and Investigation policies, emphasizing: - All allegations of abuse must be reported immediately. - Prompt initiation of investigations upon receiving allegations. - Documentation of each step of the investigation process. - Implementation of protective measures during investigations. - Timely reporting of findings and corrective actions taken. Abuse Binders were placed in each nursing station with an investigation checklist to guide staff with proper documentation and timely follow-up. The Administrator (Abuse Coordinator) will review all incident reports weekly to confirm that any allegations are promptly investigated and resolved according to policy. How the facility will monitor its performance to ensure solutions are sustained: The Administrator (Abuse Coordinator), DON, and Medical Records Director will audit all investigation files weekly for the months of June to September 2025 to ensure allegations are investigated promptly and thoroughly, with documentation completed accurately. Results will be reviewed during monthly QA meetings, and trends or gaps will be addressed immediately. Quarterly reviews will continue thereafter to ensure continued compliance with regulations. The Administrator and Medical Records Director will oversee ongoing compliance, ensuring all allegations are investigated and resolved promptly.