Failure to Report, Investigate, and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention, reporting, and investigation policies following a physical altercation between two residents. On the morning of the incident, staff heard a commotion and discovered that one resident had sustained a visible mark on the forehead, allegedly caused by another resident. Staff members separated the residents and reported the incident to the Administrator, who instructed them not to report the event further. No documentation of the incident was made in either resident's clinical records, and no notifications were sent to responsible parties or physicians. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the Department of Public Health, local law enforcement, the Ombudsman, or Adult Protective Services. The Administrator, who was also the designated Abuse Prevention Coordinator, did not initiate or document an investigation, nor did he interview involved staff or witnesses. Staff members did not complete required forms or document the injury and failed to develop or update care plans for either resident involved in the altercation. Both residents had significant cognitive impairments and behavioral symptoms documented in their medical histories, with one resident unable to make decisions and the other requiring moderate assistance with mobility. The lack of documentation, reporting, and care planning following the incident meant that the facility did not take steps to protect the residents from further harm or address the underlying behavioral issues. The facility's failure to follow its own policies placed the residents and others at risk for further abuse and neglect.