Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple residents' allegations of abuse by another resident with a known history of aggression. One resident reported being scratched under the eye by the aggressive resident, with staff and medical records confirming the presence of injuries and the aggressive behaviors. Despite these reports and physical evidence, the facility's investigation concluded that there was no credible evidence of abuse, and the incident was not substantiated. Staff interviews confirmed that the aggressive resident had a pattern of violent behavior, including throwing furniture and attacking others, and that interventions such as 1:1 sitters were inconsistently applied. Another resident described being attacked and nearly choked by the same aggressive resident after he followed her into her room. Although staff responded to her calls for help and intervened before physical contact was made, the resident reported significant fear and anxiety following the incident. The resident was not formally interviewed by management, and no investigation was conducted regarding her abuse allegation, despite her request for a room change and ongoing distress. Staff involved in the incident also reported not being interviewed by management. A third resident, who had since been discharged, reported being physically attacked and scratched by the same aggressive resident in the therapy gym, with staff present and confirming the incident. The facility's investigation again concluded that there was no credible evidence of abuse. The facility's abuse prevention policy required thorough investigation and interviews of all involved parties, but interviews with the DON and Administrator revealed that some allegations were not investigated based on their belief that the aggressive resident's actions were not willful due to his medical condition. The facility did not follow its own policy for investigating and substantiating abuse allegations.