Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with vascular dementia, schizoaffective disorder, mood affective disorder, and moderate intellectual disabilities. According to a facility incident report, a certified medication aide (CMA) witnessed another resident hit the affected resident in the face without provocation, and the local police were notified and present at the facility. However, the investigation documentation for this incident did not include any staff or resident statements regarding what occurred. The Director of Nursing (DON) confirmed that the investigation lacked these statements and was not thorough, which is inconsistent with the facility's abuse prevention policy requiring timely and comprehensive investigations of all abuse allegations.