Failure to Thoroughly Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide evidence that an alleged violation involving a resident-to-resident altercation was thoroughly investigated. Specifically, there was no documentation indicating whether the Ombudsman or law enforcement were notified, and the investigation lacked witness statements from staff members. The incident involved two residents in a secure unit, one of whom reported being hit in the eye by his roommate, resulting in redness to the eyelid. The event was not witnessed by staff, but immediate actions were taken to separate the residents and notify the Director of Nursing (DON) and Social Worker (SW). Both residents involved had histories of dementia and behavioral issues, including verbal and physical aggression and wandering. One resident had a BIMS score indicating severe cognitive impairment, while the other had moderate impairment and hemiplegia. The care plans for both residents did not fully address the aggressive behaviors or the specific altercation, and documentation showed that one resident was moved to another room following the incident. Progress notes indicated that staff observed threatening behavior and physical aggression, but the facility's Provider Investigation Report (PIR) did not include required notifications or staff interviews. Interviews with the interim and previous administrators revealed inconsistencies in reporting and investigation practices. The interim administrator stated that abuse allegations should be reported to the state, Ombudsman, and police, and that staff interviews should be conducted, but she was unable to locate the full investigation report. The previous administrator claimed to have completed an internal investigation and staff interviews but did not report the incident to law enforcement, citing the residents' dementia and confusion. The facility's abuse and neglect policy required immediate reporting and notification of law enforcement for reasonable suspicion of a crime, but there was no evidence these steps were followed.