Failure to Timely Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated and reported within the required timeframe. Specifically, when a resident reported that her roommate hit her and twisted her arm, the incident was not fully investigated and the Provider Investigation Report (PIR) was not submitted to the State Survey Agency within the mandated five working days. The PIR, which was due within five days of the incident, was instead submitted nearly three weeks later. The residents involved included one with moderately impaired cognition due to dementia and another with severely impaired cognition and a history of agitation. The initial allegation was documented by an LVN, who assessed the resident and notified the DON, administrator, responsible party, and nurse practitioner. The resident's arm was examined, and an X-ray was ordered, but there was no evidence of injury. The roommate denied the allegation. Despite these actions, the required comprehensive investigation and timely reporting were not completed as per facility policy and state regulations. Interviews with facility staff revealed confusion regarding the roles and responsibilities for investigating and reporting the incident. The DON and administrator both acknowledged delays and gaps in the investigation process, including late completion of safe surveys and failure to locate or submit the PIR on time. Review of facility policy confirmed the requirement for thorough investigation and reporting of all allegations within five working days, which was not met in this case.