Failure to Report and Investigate Resident-to-Resident Physical Incident
Penalty
Summary
The facility failed to ensure that staff reported and investigated a physical incident between two residents, one of whom had severe cognitive impairment and multiple behavioral health diagnoses, including dementia, major depressive disorder, and anxiety. The resident's care plan indicated a need for staff assistance with activities of daily living and highlighted behaviors such as restlessness, aggression, and a dislike of others in close proximity. On the evening in question, the resident exhibited increased anxiety and physical aggression, refused to use his walker, and attempted to sit in seats occupied by other residents. At one point, he tried to push another severely cognitively impaired resident and made physical contact with her chest. Staff intervened and redirected the resident, but the incident was not reported to administration or investigated as required by facility policy. Administrative staff confirmed they were unaware of the incident and stated that such events should be reported to the unit supervisor and administration for investigation and possible reporting to state authorities. The facility's policy mandates immediate reporting of abuse, neglect, or mistreatment, including resident-to-resident altercations, to the administrator and appropriate authorities. Despite recent staff training on abuse and neglect reporting, the nurse involved did not report the incident, resulting in a failure to follow established procedures for investigating and documenting potential abuse or mistreatment.