Failure to Investigate and Educate Staff Following Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of abuse involving two residents, both with severe cognitive impairment. One resident was witnessed striking another multiple times in the chest, after which the victim expressed fear and distress. The incident was documented, and the aggressor was removed from the area, but the investigation did not include documented staff education to prevent further abuse or altercations among residents. Subsequent review of records and staff interviews revealed that no education on abuse or aggression prevention was provided to staff following the incident. Although interventions were implemented to keep the two residents separated, staff, including LPNs, RNs, and CNAs, confirmed they did not receive specific training or education on preventing abuse or aggression. The Director of Nursing also confirmed that no such education was provided, and only a sign was posted and care plans updated.