Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two roommates. According to progress notes, an incident occurred between the two residents, resulting in one being moved to another room. Documentation indicated that a skin assessment was performed and no injuries were noted, but there was no further documentation in the electronic health records regarding the incident for either resident. The facility's abuse policy requires prompt and aggressive investigation and documentation of all reports and allegations of abuse, neglect, or mistreatment, but this was not followed in this case. Interviews revealed that the administrator interviewed both residents about the incident but did not document these interviews in the health records. Additionally, the administrator did not interview staff who were aware of the incident, including the LPN on duty at the time. The administrator stated that she believed she had enough information and did not pursue a further investigation, and there was no other documentation or investigation record regarding the incident.