Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for a resident with a history of dementia, depression, and insomnia, who was assessed as having intact cognition and judgment. The resident reported being struck multiple times by another resident using a walking stick, expressing distress over not being informed about the incident or its consequences, and requesting police involvement. There was no documentation that the police were contacted or that the resident was communicated with by management regarding the incident. Progress notes indicated that the nurse did not witness any physical aggression and found no injuries, but stated that both residents would be monitored closely. However, there was no documentation of the identity of the alleged perpetrator or evidence of increased monitoring for either resident. The social worker confirmed knowledge of the alleged perpetrator's identity but did not document it or contribute to a formal investigation. The DON acknowledged that an investigation was required but confirmed there was no written record of interviews or evidence that the abuse allegations were thoroughly investigated.