Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of resident-to-resident physical abuse as required by its own policies and state regulations. A resident reported that another resident entered his room, rummaged through his belongings, physically struck him, and threw his cell phone, causing it to hit him in the face. The resident immediately informed both a licensed practical nurse and the registered nurse in charge, expressing a desire for the police to be called. Despite this, staff told the resident to wait until the Administrator could conduct her own investigation, and no investigation or interviews were conducted with the resident or other involved parties. Text message correspondence between the resident and the Nursing Home Administrator confirmed that, weeks after the incident, no one had spoken to the resident about the event. Interviews with the Administrator, assistant director of nursing, and social services staff confirmed that the facility did not investigate, obtain witness statements, or notify law enforcement or the Department of Health regarding the allegation. The Administrator stated that the lack of witnesses was the reason for not investigating or reporting the incident, which is contrary to facility policy and regulatory requirements.