Failure to Protect Residents from Abuse and Inadequate Documentation of Injuries
Penalty
Summary
The facility failed to protect two residents from abuse during an altercation in which one resident hit another on the head, and the second resident responded by grabbing the first resident's forearm, causing skin tears. Both residents had a history of dementia and moderate cognitive impairment, as indicated by their BIMS scores and care plans, which included interventions for resident-to-resident altercations. Staff witnessed the incident in the dining room, and it was documented that first aid was administered to the resident who sustained skin injuries. Despite the incident and the facility's policy requiring a full head-to-toe assessment and documentation of any injuries following abuse, there was no evidence in the clinical record that the resident's skin injuries were assessed or documented. The nursing staff did not record the location, measurements, or description of the injuries, nor did they document the treatment provided, as required by facility protocol. The DON and a licensed nurse confirmed that the assessment and documentation were missing from the resident's clinical record, despite expectations and policy. Observations and interviews with both residents confirmed the occurrence of the altercation and the resulting injuries. The resident who sustained the skin tears described the incident and the resulting pain and bleeding, while the other resident was unable to recall the event due to memory impairment. Staff interviews corroborated the sequence of events and the lack of proper documentation following the incident.