Failure to Document and Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to complete incident reports or document two resident-to-resident altercations involving a resident with moderately impaired cognition, dementia, and diabetes. The resident was documented in progress notes as having shoved another resident's wheelchair and used inappropriate language on multiple occasions. Staff intervened verbally at the time of the incidents but did not complete incident reports or document follow-up with the other residents involved. The Director of Nursing confirmed that no incident reports were completed for these events because no injuries occurred. Staff interviews revealed that the LPN involved did not chart or follow up with the other residents involved in the altercations and did not recall specific details about the incidents. The facility's policy required that all accidents or incidents involving residents be investigated and reported, including documentation of circumstances, those involved, and corrective actions taken. Despite this policy, the required documentation and reporting were not completed for the incidents in question.