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 two of five residents reviewed. Staff documented observations of resident-to-resident altercations involving two residents on the same date, but there was no indication that these incidents were investigated by the facility as required by their abuse prohibition policy. The policy mandates immediate investigation when there is suspicion or report of abuse, neglect, or exploitation. Surveyors reviewed a progress note authored by an LPN, which described an incident where one resident yelled profanities at another, threw a wander guard in the direction of a resident, and later slammed a walker into a chair while making a threatening statement to a different resident. During an interview, the Nursing Home Administrator confirmed that these events should have been investigated as allegations of abuse, but no investigation was conducted.