Failure to Adhere to Abuse Prevention Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy following an incident of resident-to-resident abuse involving two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, Asperger's syndrome, and behavioral problems including physical aggression, physically grabbed another resident's arm and attempted to drag him to the floor. Staff intervened with difficulty, and the aggressor attempted to throw a chair but was stopped. The resident expressed indifference when told not to abuse others. The victim, who also had multiple psychiatric and medical diagnoses, was found with slight discoloration on his arm and a ripped shirt sleeve after the altercation. Documentation indicated that the incident was recognized as abuse by the administrator and abuse coordinator. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the investigation documentation could not be provided for review beyond 12 months. The facility's policies, revised in 2021 and 2022, clearly state the requirement for immediate reporting and investigation of abuse, as well as the right of residents to be free from abuse, neglect, and exploitation. However, the lack of available investigation records and the events described indicate that the facility did not fully implement or adhere to these policies in response to the incident.