Failure to Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report and investigate allegations of physical abuse involving two residents. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, including diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and a psychotic disorder, was observed on multiple occasions following, yelling at, and physically striking another resident. On two separate dates, staff documented that the resident slapped another resident in the face, and in one instance, attempted to do so again shortly after being redirected. In both cases, staff intervened, redirected the resident, and noted that the other resident did not sustain injuries or complain of pain. Despite these documented incidents of resident-to-resident physical abuse, the facility did not report the events to the State Agency as required, nor did they conduct an investigation into the allegations. The Director of Nursing confirmed during an interview that these incidents were not reported or investigated because there were no injuries, indicating a misunderstanding of reporting requirements. The facility only reported a later incident involving a push, not the slapping incidents, which were omitted from required notifications and follow-up.