Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, verbally threatened another resident in the dining room. This incident was witnessed by an activity aide, who reported it to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA), but was not asked to provide a written statement. The resident who was threatened had severe cognitive impairment due to dementia and other medical conditions. Multiple staff members and a family member reported that this resident was being targeted and verbally threatened by a group of residents, including the resident who made the threat. Despite these reports, the DON and NHA did not conduct a thorough investigation. The DON stated that the information provided did not indicate abuse and therefore did not warrant further investigation. The NHA recalled only a brief, in-the-moment inquiry and did not remember the incident reported by the activity aide. The facility's policy requires investigation of all alleged violations, including interviewing all involved persons and witnesses, but this was not followed. As a result, the potential for the allegation to not be thoroughly investigated and for further abuse to occur remained.