Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving three residents with severe cognitive impairment. Incident reports documented physical altercations between residents, including one event where a resident removed another's hat, leading to both residents swinging at each other and one making contact with the other's back. Another incident involved a resident becoming agitated, grabbing another resident's arm, and a physical struggle ensued, resulting in pain and minor injury to both residents and a CNA who intervened. Despite these documented events, there was no evidence that the facility initiated investigations or reported the incidents to the appropriate state agency as required by policy. Interviews with the Nursing Home Administrator (NHA), who also served as the facility abuse coordinator, revealed that she was not notified of the incidents at the time they occurred. Upon review of the incident reports during the survey, the NHA acknowledged that the events constituted allegations of abuse and should have been investigated and reported. The NHA also confirmed that she had signed the incident reports after the fact but had not initiated any investigation or reporting process prior to the surveyor's inquiry. Facility policy required immediate investigation and reporting of any suspicion or report of abuse, including resident-to-resident altercations. The policy defined physical abuse to include actions such as hitting, slapping, and grabbing. Despite this, the facility did not follow its own procedures, as the incidents were neither investigated nor reported in accordance with state and federal regulations. The failure to act was confirmed through record review, staff interviews, and the absence of investigation documentation.