Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate resident-to-resident abuse allegations, as evidenced by incomplete documentation and lack of witness statements. In the first incident, a resident-to-resident abuse allegation occurred involving two residents. The investigation packet included a statement from the first staff member on the scene, a Unit Manager, who called for assistance from a Physical Therapist. However, the facility did not obtain a witness statement from the Physical Therapist, who was also present at the scene. The Administrator confirmed that a statement from this staff member should have been included to ensure a comprehensive investigation. In the second incident, two residents were involved in a verbal and physical altercation during a group activity. The facility's event report included written accounts from three staff members who witnessed the event. The Director of Nursing stated that she interviewed these staff members but could not provide documentation of the interviews. Additionally, no interviews were conducted with other residents who attended the activity where the altercation occurred. The facility's policy requires identifying and interviewing all involved persons and witnesses, but this was not followed in these cases.