Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident allegation of abuse involving two cognitively intact residents. The incident occurred in the smoking area, where a disagreement led to one resident making physical contact with the other's cheek. The affected resident reported moderate pain and was assessed by nursing staff, who found no visible injuries. Both residents were separated, and notifications were made to the physician, DON, Administrator, and resident representatives. However, the investigation documentation included only a written statement from an LPN who did not witness the event and a summary of brief interviews with the involved residents. The resident who was struck reported feeling embarrassed and uncomfortable after the incident, noting swelling on his face and a sense of unease around the other resident. He also expressed that staff did not address his feelings privately and that he continued to feel uncomfortable, choosing to smoke in his truck to avoid further misunderstandings. Despite these ongoing concerns, the Administrator was unaware of the resident's discomfort and did not interview other residents or staff who may have witnessed the incident or had relevant information. The facility's policy required all accidents or incidents to be investigated and reported to the Administrator, but the investigation was limited to statements from the involved residents and a non-witnessing LPN. No additional interviews or broader inquiry were conducted to fully assess the circumstances or psychosocial impact. The lack of a comprehensive investigation did not meet the facility's policy or regulatory expectations for handling resident-to-resident abuse allegations.