Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough and timely investigation following an allegation of resident-to-resident verbal abuse involving two residents. One resident, with little to no cognitive impairment, reported feeling uncomfortable and requested a room change after his roommate repeatedly used foul language towards him. Progress notes indicated that the other resident, who had moderate cognitive impairment and a history of restlessness and agitation, was observed rummaging through his roommate's belongings and made threatening statements, including a threat to kill his roommate. Staff attempted to redirect the aggressive resident without success, and the residents were separated. A mental health evaluation was initiated for the aggressive resident. Despite the seriousness of the incident, the Social Service Director (SSD) did not follow the facility's abuse investigation policy. The SSD acknowledged being informed of the threat and attempted to de-escalate the situation but did not contact law enforcement or the Ombudsman, and failed to document interviews or conduct further investigative tasks. Other staff, including an LPN, witnessed the incident but did not provide additional documentation. The Director of Nursing and Administrator confirmed that proper reporting and investigative procedures were not followed, and no investigation file could be located for the incident.