Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an alleged incident of resident-to-resident abuse involving a resident with severe cognitive impairment. According to the facility's Abuse and Neglect policy, any reported incident of abuse requires immediate investigation by the administrator or designee, including interviews with the resident, roommates, other residents, staff, and witnesses, as well as documentation of injuries and environmental factors. However, when staff documented that a resident had a black eye and bruising to the shoulders and that the resident stated someone hit them, there was no evidence in the nurse's notes or other records that an investigation was initiated or completed. Interviews with staff revealed that the LPN reported the injuries and the resident's statement to the DON, but the DON did not conduct a formal investigation, citing the resident's history of self-injury as the reason. The administrator confirmed that allegations of abuse should be reported and investigated but stated that in this case, the allegations were not investigated or reported to the state because they had not been formally reported to the DON or administrator. The lack of investigation and documentation was contrary to the facility's policy and regulatory requirements.