Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of resident-to-resident physical abuse was not reported or investigated. A female resident with major depressive disorder and major neurocognitive disorder due to Alzheimer's disease, who had a history of physical aggression toward staff, was alleged to have hit her roommate on the left hand. The incident was documented in a progress note by a registered nurse, but there was no evidence that the allegation was reported to the abuse coordinator as required by facility policy. The nurse assessed the resident and found no injury, and believed the interaction was playful based on the residents' relationship, but did not document all details in the chart or initiate the required reporting process. Interviews revealed that the nursing home administrator was not made aware of the allegation, and staff did not follow the policy for immediate reporting of abuse allegations. The facility's written policy requires all alleged violations to be reported to the administrator and investigated, but this process was not followed in this case. The failure to report and investigate the allegation resulted in noncompliance with the facility's abuse prevention and response procedures.