Failure to Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving two residents. According to the facility's own Abuse Prevention Program Policy, all reports and allegations of abuse must be promptly and aggressively investigated, with immediate protection for the residents involved. However, after an altercation in the dining room where one resident kicked another multiple times in the knees, the administrator only interviewed the resident who reported being kicked and did not initiate a full investigation or provide an investigation report. No assessment or follow-up was conducted to check for injuries or offer pain management to the resident who was kicked. Multiple staff interviews revealed that the incident was not communicated to key personnel, including the DON, and was not discussed in staff meetings. The CNA who witnessed the altercation reported it to the administrator, but no further action was taken to separate the residents or evaluate the aggressor for behavioral interventions. Other staff and residents described ongoing behavioral issues with the resident who committed the kicking, including frequent yelling and aggressive behavior, but these concerns were not addressed or documented in care planning or meetings. The facility's failure to follow its abuse investigation policy and to protect residents from further potential abuse affected not only the two residents directly involved but also had the potential to impact all 79 residents in the facility. The lack of documentation, communication, and follow-up after the incident demonstrates a breakdown in the facility's systems for identifying, investigating, and responding to abuse allegations as required by policy.