Failure to Report and Investigate Alleged Physical Abuse Between Residents
Penalty
Summary
The facility failed to ensure that allegations of physical abuse involving two cognitively impaired residents were reported and investigated as required. Multiple incidents occurred in which one resident physically assaulted another, resulting in injuries such as a skin tear and extensive bruising. Documentation showed that staff and family witnessed at least one altercation, and there were several documented injuries, including a 1-centimeter skin tear and multiple bruises of varying sizes on the resident's legs. Despite these events, there was no evidence of follow-up documentation, investigation, or required reporting to authorities. Additionally, the facility's records indicated that staff were instructed not to document the altercations, and the administrator was not informed of the extensive bruising or the circumstances surrounding the repeated altercations. There was also a lack of documentation regarding the assessment of injuries, such as the color of bruises or pain evaluation, and no investigation into injuries of unknown origin. The facility's policy required immediate reporting and investigation of abuse allegations, but these procedures were not followed in the cases reviewed.