Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
A resident-to-resident altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, including dementia and cerebral infarction. The incident involved verbal and physical aggression, with yelling, swearing, and the use of mobility aids in a physical confrontation. Documentation in the medical record described the altercation, and interviews with both residents confirmed the occurrence, with one resident recalling the argument and physical contact, and the other unable to recall the event. Despite the facility's policy requiring immediate investigation of any alleged abuse, neglect, or exploitation, there was no evidence that a thorough investigation was conducted following the altercation. The Director of Nursing was unaware of the full extent of the incident and confirmed that no investigation had been initiated. This failure to investigate was in direct violation of the facility's own policies and procedures regarding the handling of abuse allegations.