Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents, both of whom had significant cognitive impairments and complex medical histories, including schizoaffective disorder, dementia, and psychosis. Documentation revealed that one resident became agitated and, on multiple occasions, was observed yelling at and pushing another resident. Nursing notes and staff statements described the incident, but there were inconsistencies and missing information in the facility's investigation. Notably, the investigation did not include statements from the residents involved, despite the self-reported incident form indicating they could provide meaningful information. The facility's investigation relied on handwritten statements from staff, some of whom did not witness the incident directly, and omitted key statements that were later found on the unit manager's desk. The Regional Director of Operations was unable to clarify who initially reported the incident, to whom it was reported, or when the allegation was brought to their attention. Additionally, the facility's documentation did not align with the events described in nursing notes, and there was a lack of timely and complete reporting as required by facility policy. The facility's policy mandated immediate reporting of all allegations of abuse to the administrator or designee and to the state health department. However, the investigation was incomplete, with missing resident statements and unclear timelines regarding when the incident was reported. This deficiency was noted as a continuation of non-compliance from a previous survey.