Failure to Timely Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting and investigation of a resident-to-resident altercation involving two residents. One resident, who had intact cognitive skills and required moderate assistance with activities of daily living, reported that another resident, who had moderately impaired cognition and a high risk of wandering, entered his room, sat on his bed, and opened his drawer. The first resident became upset and threw water at the second resident in the hallway. Progress notes documented the incident, and staff indicated they would continue to monitor the second resident's behavior. Despite the documentation of the incident, the facility did not investigate or report the event to the appropriate authorities, including the State, Local Ombudsman, or Police, as required by facility policy and federal regulations. Both the RN and DON acknowledged during interviews that the incident should have been reported and investigated, but no such actions were taken. The facility's policy mandates the identification, investigation, and timely reporting of all possible incidents of abuse, neglect, or misappropriation of resident property, which was not followed in this case.