Failure to Report and Investigate Resident Altercations
Penalty
Summary
The facility failed to report and investigate two separate incidents involving a resident with Alzheimer's disease and behavioral disturbances. In the first incident, a family member reported to the unit manager and executive director that he pushed the resident with his fingers to redirect the resident out of another resident's room. Despite the facility's policy requiring the reporting and investigation of all alleged abuse, no incident report was completed, and the event was not reported to the Department of Public Health. The unit manager acknowledged that the incident should have been reportable, but after discussion with the corporate team, no further action was taken. In the second incident, a certified nurse aide reported being punched in the face by the same resident while providing evening care. The aide informed the nurse on duty, but was not asked to write a statement, and no incident report was completed. The nurse stated she followed the unit manager's instructions, who did not recall the incident or confirm whether an incident report would have been initiated. The executive director was not made aware of this event. The facility's executive director confirmed that it is the expectation that all altercations be followed by an incident report and proper reporting, which did not occur in these cases.