Failure to Conduct Thorough Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of resident-to-resident abuse involving two residents. One resident, who was moderately cognitively impaired with a history of dementia and behavioral disturbances, entered another resident's room and a physical altercation occurred, resulting in physical contact and injury. Both residents claimed to have been struck by the other, and immediate interventions such as separation, 15-minute checks, and notifications to appropriate parties were implemented. However, the investigation report did not include statements from staff members who were present and working with the residents at the time of the incident. Multiple staff members, including CNAs and nurses who were on duty during the event, reported during interviews that they were not asked to provide statements for the investigation. The facility's policy requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, but there was no evidence that this was done. The investigation also lacked documentation regarding the presence of visitors or other employees who may have witnessed the incident, resulting in an incomplete investigation as required by facility policy.