Failure to Investigate and Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation, documentation, and reporting of a resident-to-resident abuse incident. According to facility policy, all altercations, including those that may represent abuse, are to be investigated, documented, and reported to the nursing supervisor, director of nursing, administrator, and appropriate agencies. However, when an incident occurred in which one resident with severe cognitive impairment and a history of behavioral issues grabbed another resident, also with severe cognitive impairment, by the shirt collar and pushed them in a wheelchair, the required steps were not followed. Staff separated the residents and obtained witness statements, but no incident report or risk management form was completed, and the event was not reported to the state or police as required by policy. The residents involved both had significant cognitive impairments and behavioral histories. One resident had a diagnosis of cerebral infarction and exhibited physical and verbal behaviors toward others, while the other had dementia and was noted for inappropriate behaviors. During the incident, staff observed one resident holding and pulling on the other's shirt collar, with the affected resident becoming upset and crying. Staff intervened to separate the residents, but the incident was not properly documented or reported according to facility policy. Interviews with staff and administration revealed a breakdown in communication and adherence to policy. The DON and RN involved believed the incident constituted resident-to-resident abuse and should have been reported and investigated, but the former DON and regional director determined it was not an altercation and instructed staff not to report it. The administrator was not fully informed of the details and agreed that the facility did not follow its own policy regarding investigation, documentation, and reporting. Additionally, there was no assessment to determine if the residents could safely remain roommates after the incident.