Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of abuse involving two residents. The incident began when one resident engaged in aggressive and threatening behavior, including yelling profanities, making threats, and attempting to enter another resident's room while wielding a wet floor sign and a chair. The aggressive resident threw the wet floor sign, which struck an LPN, and also threw a chair toward a door. Multiple staff members attempted to de-escalate the situation, and the resident was subsequently sent to the emergency room for evaluation and did not return to the facility. Documentation shows that the altercation caused significant distress to the other resident, who reported feeling scared, experiencing chest pain, and anxiety due to the threats made outside their door. The resident expressed concerns about their safety, particularly regarding the possibility of being attacked while asleep. Despite these concerns and the presence of multiple witnesses, the facility's investigation into the incident was incomplete, as there were no additional resident or staff interviews included in the investigation file. The facility's policy required immediate intervention and a thorough investigation of alleged abuse, including interviews and documentation of findings. However, the investigation lacked critical interviews and safe surveys, which were reportedly conducted but could not be located. This failure to fully document and investigate the abuse allegation led to the determination of non-compliance and the identification of an Immediate Jeopardy situation by the state health department.