Failure to Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to thoroughly investigate an incident involving two residents, one of whom threatened the other with a hand saw and used the saw to damage the other's walker. The incident occurred when a male resident, who had diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, obtained a hand saw from the maintenance office. He then threatened a female resident, who had Alzheimer's disease, intermittent explosive disorder, and psychotic disorder, by stating he would cut off her foot and proceeded to cut a groove into her walker. Multiple staff members, including CNAs and an LVN, observed or were informed of the incident, and the saw was taken away from the resident by staff. Despite the seriousness of the event, there was no evidence that the facility initiated or completed a thorough investigation as required by their own policies and federal regulations. Interviews with staff revealed confusion about whether the incident needed to be reported, and some staff did not communicate the event to the appropriate administrative personnel. The administrator and ADON expressed uncertainty about the necessity of reporting or investigating the incident, and there was no documentation of an investigation or protective measures taken until surveyors began asking questions. The facility's policies require that all allegations of abuse, neglect, or exploitation be thoroughly investigated, with specific steps outlined for reviewing documentation, interviewing involved parties, and protecting residents from further harm. However, in this case, the required investigation was not conducted, and the incident was not reported in a timely manner. The lack of action persisted until the survey process prompted staff to address the situation.