Failure to Assess and Address Psychosocial Needs After Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to provide medically-related social services to a resident who experienced physical abuse from another resident. According to the clinical record, a nurse documented that the resident was found being hit in the face by another resident, resulting in a small skin tear on the nose, facial swelling, and bruising. The nurse assessed the resident's physical condition, notified the nurse practitioner, obtained an x-ray order, and informed the resident's power of attorney. However, there was no documentation that the resident's psychosocial status was assessed or that any psychosocial interventions were implemented following the incident. Interviews with the social services coordinator revealed that the facility's protocol requires social services staff to interview residents involved in such incidents, complete a psychosocial assessment, and monitor the resident's coping status weekly for at least four weeks, with all actions documented in the clinical record. Review of the resident's record did not show evidence that these steps were taken. The facility's policy also mandates that social services complete progress reviews with significant changes or as needed, but no such documentation was found for this incident.