Failure to Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident physical abuse involving one of four residents reviewed for abuse. According to the facility's Abuse Prevention Program policy, the administrator or designee is required to initiate an incident investigation upon learning of any allegation of abuse. Progress notes for two residents documented that one resident pushed another, resulting in the second resident falling to the floor and landing on his left side. The administrator confirmed that he was not notified of the incident, and as a result, no investigation or reporting was conducted. The administrator also stated that all such incidents are supposed to be reported to him or his designee immediately, regardless of the time or day.