Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting and investigating two separate incidents of resident-to-resident physical abuse. In the first incident, a staff member witnessed one resident striking another on the shoulder with a shoe. Although the incident was documented and the local police were notified, the State Agency was not notified until several months later, and no abuse investigation was conducted at the time of the event. The facility administrator confirmed awareness of the incident but acknowledged that the required investigation and timely reporting to the State Agency did not occur. In the second incident, a resident was observed grabbing another resident's hair and attempting to take her walker. The involved parties were separated, and notifications were made to the health care power of attorney, physician, administrator, and director of nursing. However, the administrator stated she only became aware of the situation the following day and had not immediately initiated an abuse investigation or reported the incident to the State Agency as required by facility policy. These failures were identified for three residents reviewed for abuse in a sample of five.