Failure to Notify Physicians and Representatives After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify the physicians and representatives of two residents involved in an abuse incident, as required by policy and regulation. An altercation occurred in the dining room where one resident, who was alert, oriented, and serving as Resident Council President, was kicked multiple times in the knees by another resident using a wheelchair. The affected resident reported pain in the knees for several days following the incident and stated that no nursing staff assessed or followed up regarding the injury. There was no documentation in either resident's medical records, care plans, or nursing notes regarding the incident or any notifications to their physicians or representatives. Interviews with facility staff, including the Administrator and DON, revealed that no investigation was initiated immediately after the incident, and the event was not reported to the local State Agency until several days later. The Administrator acknowledged not investigating or reporting the incident initially, and the DON was unaware of the event, indicating a lack of communication and follow-up. The facility's policies require prompt investigation and notification in cases of abuse, but these procedures were not followed in this instance.