Failure to Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and provide complete documentation regarding an incident of physical abuse involving two residents. According to the facility's own Abuse, Neglect and Exploitation policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying and interviewing all involved persons and witnesses, and documenting the findings. However, after an altercation in the dining room where two residents kicked each other, the facility's investigation did not identify or interview all staff and resident witnesses, nor did it document their statements. The investigation noted that both residents involved had a history of aggressive behaviors, and that staff and another resident witnessed the incident. Despite this, there was no documentation of interviews with the residents involved or with the witnesses. One resident witness, who was alert and oriented, reported that she was present during the altercation and that a dietary staff member intervened, but stated that no one from the facility interviewed her about the incident, even after the police had spoken with her. Staff interviews confirmed that key witnesses, including the dietary aide who separated the residents and the resident witness, were not interviewed as part of the facility's investigation. The social service assistant acknowledged not interviewing all involved parties, and the current nursing home administrator stated that all witnesses should have been interviewed but were not. The facility's documentation and investigative process did not meet the requirements outlined in its own policy, resulting in an incomplete investigation of the abuse incident.