Failure to Conduct Thorough Investigation After Resident Altercations
Penalty
Summary
The facility failed to conduct a thorough investigation following two separate resident-to-resident altercations involving a resident with severe cognitive impairment and two other residents with no cognitive impairment. The first incident occurred when a resident with a BIMS score of 3, indicating severe cognitive impairment, grabbed another resident's wheelchair and began pushing it, then slapped the resident several times on the shoulder after he attempted to remove her hand. The second incident involved the same cognitively impaired resident, who was reported to have hit another resident in the chest during a dispute over silverware. In both cases, staff intervened promptly to separate the residents, and no injuries were reported by the residents involved. Upon review, the facility's investigative files for both incidents were found to be incomplete. The documentation provided included summaries of the investigations, face sheets, care plans, medication changes, and progress notes, but lacked staff interviews or statements and resident interviews or statements. The administrator acknowledged that only statements from the charge nurses on duty were obtained and that no additional interviews with other staff or residents were conducted. The administrator also stated that the resident with severe cognitive impairment was not interviewed due to her condition, and that she did not perceive the resident as violent or capable of causing bodily injury. The deficiency was identified based on the facility's failure to follow a comprehensive investigative process after the altercations. The lack of thorough documentation, including the absence of interviews with all involved parties, contributed to the finding that the facility did not respond appropriately to the alleged violations. The administrator admitted this was a failure in the investigative process, as the standard procedure would typically involve gathering information from all relevant staff and residents.