Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of abuse involving a resident with cognitive impairment and aggressive behaviors (R3) and another resident who was cognitively intact but physically impaired (R1). R1 reported that R3, who required 1:1 supervision due to a history of aggression, followed her into her room after throwing furniture in the hallway and attempted to choke her. Staff responded to R1's screams, and although some staff stated they intervened before physical contact occurred, R1 consistently reported feeling attacked and extremely scared. R1's emotional distress was documented, and she was moved to another unit at her request. Despite these events, there was no documented investigation or reporting of the abuse allegation to the appropriate authorities as required by facility policy. Interviews with staff revealed that the assigned sitter for R3 had left him unsupervised, allowing the incident to occur. The DON and Administrator acknowledged being notified of the incident but did not initiate an investigation or report the allegation, citing staff belief that no physical contact had occurred. The facility's abuse prevention policy required all allegations or suspicions of abuse to be reported and investigated, but this protocol was not followed in this case. No internal investigation or external reporting was conducted regarding R1's allegation, and the facility failed to ensure the safety and proper follow-up for the resident involved.