Failure to Report and Document Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report, complete, and submit a thorough investigation of a resident-to-resident altercation involving two residents. According to the facility's own Abuse and Neglect Prevention policy, all acts of witnessed, suspected, or reported abuse must be immediately reported to the Administrator or supervisor, and all incidents must be investigated and reported in accordance with state and federal laws. On the date of the incident, one resident with cognitive impairment and a history of aggressive behaviors, including slapping and cursing staff, was observed by staff to have slapped another resident's hand during an argument at the dining table. The altercation occurred when the second resident attempted to assist with cutting food, which was not wanted by the first resident. The incident was witnessed by staff, and both the Assistant DON and Administrator were notified. Despite the facility's policy requiring immediate reporting and thorough investigation, the altercation was not reported as required prior to the investigation. The facility determined after the fact that no abuse had occurred, citing that both residents considered themselves friends and the interaction was playful, but this determination was not documented in the charting of the incident. The failure to report the altercation and to document the investigation findings as required constituted a deficiency in compliance with state regulations.