Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple diagnoses, including anxiety, dementia, and major depressive disorder, was subjected to resident-to-resident abuse. The incident involved another resident with severely impaired cognition who grabbed the first resident's knee, causing redness but no bruising. The event was witnessed by a CNA, who intervened to separate the residents and reported the incident to a nurse for assessment. Despite the facility's policies requiring immediate reporting, investigation, and notification of administration, physician, and family, there was a lack of proper documentation and follow-up. The electronic medical record did not include further assessment or documentation of follow-up after the altercation, nor did it show that nursing administration, family, or physician were notified. The nurse involved admitted to not completing an incident report or notifying administration as required, and only verbally informed the family without documentation. Key staff members, including the administrative nurse and social services, were unaware of the incident until much later, indicating a breakdown in communication and protocol adherence. The facility's policies clearly outlined the steps to be taken in the event of resident-to-resident abuse, but these were not followed, resulting in a failure to protect the resident from abuse and to ensure appropriate post-incident actions were taken.