Failure to Implement Abuse Policy Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy following an incident involving two residents, one of whom had significant cognitive and medical impairments, including dementia and a cognitive communication deficit. On the date of the incident, one resident was calling for help, which agitated his roommate. The roommate physically interacted with the resident, making contact with his chest and head. A CNA witnessed the event, describing the contact as aggressive, with the resident being struck on the chin and head. The CNA intervened, separated the residents, and reported the incident to nursing and administrative staff. Despite the facility's policy requiring immediate notification, monitoring, alert charting, and assessment for injury following any suspected abuse, the clinical record lacked documentation of the incident, monitoring, alert charting, notification to the medical provider, or assessment for injury for the resident involved. Interviews with staff revealed inconsistent interpretations of the event, with the CNA describing it as aggressive and the administrator characterizing the contact as unintentional and not abusive. The facility ultimately did not substantiate the incident as abuse, citing a lack of evidence, despite direct witness testimony to the contrary. The facility's abuse policy outlined specific steps to be taken when abuse is witnessed or suspected, including immediate investigation, notification of relevant parties, and monitoring of the resident. However, these procedures were not followed as required, as evidenced by the absence of documentation and monitoring in the resident's clinical record after the incident. This failure to implement the abuse policy constituted a deficiency that could lead to harm for residents.