Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving a resident with major depressive disorder, anxiety, paraplegia, and other chronic conditions, who sustained a skin tear on her left forearm after another resident with Alzheimer's disease and severe cognitive impairment grabbed her arm. The incident was documented in nursing progress notes, which indicated that the injured resident reported pain, a skin tear, and fear following the event. Despite documentation of the injury and the resident's expressed fear, staff did not recognize or report the event as a potential abuse incident at the time it occurred. Staff, including an LPN, did not assess the injured resident for emotional distress or document the presence of a bruise, and the incident was not reported to facility administration as a resident-to-resident altercation. The administrator and other leadership were unaware of the event until it was brought to their attention weeks later, at which point an investigation was initiated. The facility's policy requires prompt reporting and investigation of suspected abuse, but this was not followed in this case, resulting in a failure to respond appropriately to an alleged violation.