Failure to Report Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when staff failed to report a resident-to-resident altercation to administration, as required by facility policy. The incident involved a resident with moderately impaired cognition, anxiety, dementia, and major depressive disorder, who was grabbed above the right knee by another resident with severely impaired cognition. The altercation resulted in redness to the knee but no bruising or further injury. The event was documented in the nurse's notes, and the resident was assessed and removed from the situation, but there was no further documentation or follow-up regarding the incident. The electronic medical record lacked evidence of additional assessment, follow-up, or notification to nursing administration, the resident's family, or the physician after the altercation. Interviews revealed that key staff members, including the administrative nurse and social services, were unaware of the incident until much later. The nurse involved acknowledged that an incident report should have been completed and administration notified, but this was not done. The facility's policies require immediate reporting and investigation of such incidents, as well as notification of families and physicians. Staff interviews confirmed that training on abuse and behavior management was provided, and that the expected protocol was to separate residents and notify the nurse for assessment. However, the required steps for reporting and investigating the altercation were not followed, resulting in a failure to comply with the facility's abuse and neglect policies. This lapse placed the resident at risk for further injury and unaddressed abuse or mistreatment.