Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy when two residents were involved in a physical altercation. Both residents had documented histories of potential aggression, with care plans indicating the need for interventions and monitoring. Following the incident, one resident was observed to have a mark under the eye, and a family member reported the resident had a black eye as a result of being punched. Staff interviews confirmed that a physical altercation occurred, with one resident grabbing and hitting the other, leading both to fall to the floor. Immediate assistance was called, and both residents were assessed by nursing staff, with recommendations for hospital evaluation. Despite the clear evidence of a resident-to-resident altercation resulting in injury, the facility did not initiate a thorough investigation as required by its Abuse Prevention Policy. There was no documentation of an investigation, and key staff members, including the Activity Director and Certified Nurse Aide who witnessed or responded to the incident, were not asked to provide written statements. The incident was not reported to the State Survey Agency or other required officials, and there was no documentation of the event in the residents' nurse's notes beyond the initial hospital referral. Interviews with facility leadership, including the Regional Director of Nursing and the Administrator, revealed that the incident was not reported or investigated according to policy. The Administrator acknowledged responsibility for ensuring the policy is followed and for reporting abuse and neglect allegations but was unable to explain why the required actions were not taken. The lack of investigation and reporting represents a failure to protect residents from abuse and to comply with regulatory requirements.