Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an incident of resident-to-resident abuse as required by policy and state regulations. On the date of the incident, staff observed one resident using a walker to make physical contact with another resident after a verbal exchange in the hallway. Staff intervened to prevent further confrontation. Both residents involved had incident reports completed, but these reports did not include any investigation of the event. Additionally, there were no progress notes or documentation in either resident's medical record regarding the incident or any investigation. The facility's policy requires that all alleged or suspected abuse be promptly reported, thoroughly investigated, and submitted to the state agency within five working days. However, the Director of Nursing confirmed that no investigation was conducted or submitted to the state agency for this incident. The care plan for the resident who initiated the contact indicated a history of aggressive behavior and the need for supervision in public areas, but there was no evidence that these interventions were followed up in response to the incident.