Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving two residents, one of whom had significant cognitive and physical impairments, including dementia, Parkinson's disease, and nonverbal status. The incident occurred when a nurse aide overheard yelling, entered the hallway, and observed one resident kicking another, who was attempting to back away but was slow moving and nonverbal. The nurse aide immediately separated the residents and notified the unit manager, who performed an initial assessment and found no visible injuries. However, no further assessments were conducted to evaluate for delayed physical injuries or mental anguish, despite the nonverbal resident's grimacing during the incident. Documentation and staff interviews revealed inconsistencies in the accounts of the incident, with some staff stating that physical contact occurred and others stating it did not. The facility's policy required a thorough investigation of all abuse allegations, including interviews with all involved parties and assessments for both physical and psychological harm. Despite this, the investigation folder lacked statements from all potential witnesses, did not address conflicting accounts, and did not include follow-up assessments for injuries that may have appeared later or for possible mental distress. Key staff, including the social workers and the administrator, did not initiate a formal investigation, citing the absence of injury as the reason. The administrator and social workers did not amend their statements to resolve discrepancies or document further inquiry, even after one resident admitted to kicking the other. The director of nursing was not directly informed, and there was no evidence that the incident was reported to required authorities as per facility policy. The lack of a comprehensive investigation and documentation failed to meet regulatory requirements for abuse prevention and response.