Failure to Conduct Thorough Investigation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following an alleged abuse incident involving two residents. According to the facility's policy, when an incident or suspected incident of abuse is reported, the investigation should include resident statements. In this case, a resident-to-resident altercation occurred when one resident struck another in the head with a remote after a verbal exchange. Both residents involved were cognitively intact, as indicated by their Brief Interview Mental Score (BIMS) of 15 out of 15. Law enforcement was called, and the residents were separated immediately following the incident. Despite the policy requirements, the investigation did not include interviews with other residents or further investigative steps beyond the immediate response. Staff interviews revealed that no one was instructed to interview other residents or provide additional education to staff. The DON confirmed that no further investigation was conducted, believing the event to be isolated. This lack of a comprehensive investigation did not align with the facility's policy and left the incident insufficiently examined.