Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of resident-to-resident physical abuse involving two residents. In the first incident, one resident requested a CNA to remove their roommate due to inappropriate behavior, which escalated into a physical altercation where the resident shoved the roommate. The investigation file did not include documentation of who reported the allegation to the administrator, whether other residents were interviewed, if additional witnesses were present, or any specific and immediate interventions implemented to protect residents from further abuse. The administrator confirmed that the investigation file was complete and contained the entire incident investigation. In the second incident, a CNA overheard residents yelling and intervened in a room where one resident was standing over another, yelling. As the CNA intervened and escorted one resident out, that resident struck the other in the head. The investigation included a statement from an LPN who received the report but did not document who reported the allegation to the administrator or any specific and immediate interventions or long-term measures to prevent further abuse. The administrator again confirmed the investigation file was complete. Both incidents lacked thorough documentation and failed to meet the facility's abuse prevention and reporting policy requirements.