Failure to Conduct Thorough Investigation After Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses. According to facility policy, an immediate and documented investigation should be initiated and continue for at least 72 hours after any alleged abuse. However, after an incident where one resident was witnessed striking another near the neck, shoulder, and head area, the only documented actions were immediate separation and assessment of the residents, notification of the physician and DON, and initiation of 15-minute checks for the resident who initiated the contact. The Assistant Director of Nursing later confirmed that a thorough investigation should have been completed, indicating that the required investigative process was not followed.