Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident diagnosed with Alzheimer's disease, vascular dementia with agitation, psychotic disorder with delusions, and delirium. According to the nurses note, the resident was observed pulling another resident's hair, and staff intervened immediately. However, a review of the Enhanced Information Dissemination and Collection system (EIDC) revealed that no Self-Reported Incident (SRI) was filed for this event. Interviews with the DON and Executive Director confirmed the existence of the incident in the medical record and acknowledged that an SRI should have been completed, but was not. The facility's policy requires immediate investigation and reporting of abuse allegations to the appropriate agencies within 24 hours, which was not followed in this case.