Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect for multiple residents. Specifically, the facility did not initiate investigations or report incidents of resident-to-resident altercations as required by its policy. For example, one incident involved a resident with severe cognitive impairment who was involved in a physical altercation with another resident over a personal item, resulting in physical contact. The incident report documented the altercation, but the Nursing Home Administrator (NHA), who is also the facility abuse coordinator, was not notified and did not investigate or report the event to the appropriate state agency. Another incident involved a resident with severe cognitive impairment and multiple comorbidities who was physically grabbed by another resident, leading to pain and minor injury. The incident report documented the event, including the resident's complaints of pain and the involvement of a certified nursing aide (CNA) who intervened. Despite the documentation and the facility's policy requiring immediate investigation and reporting of suspected abuse, the NHA was not aware of the details and did not initiate an investigation or report the incident to the state agency. Record review confirmed that the NHA signed the incident reports days after the events occurred, but there was no evidence of timely investigation or reporting as required by the facility's abuse, neglect, and exploitation policy. Interviews with the NHA revealed a lack of awareness of the incidents and a failure to follow the facility's procedures for investigating and reporting allegations of abuse, particularly in cases involving resident-to-resident altercations resulting in physical contact and injury.