Failure to Document Details of Resident-to-Resident Abuse Allegations and Investigations
Penalty
Summary
The facility failed to fully document the details of resident-to-resident physical abuse allegations and subsequent investigations in the medical records of the residents involved. In two separate incidents, altercations occurred between two residents, with one resident physically assaulting another. The facility's abuse investigation files contained some details about the events, such as the sequence of actions and statements made by those involved, but lacked documentation regarding who reported the allegations to the administrator, whether other residents were interviewed, the presence of additional witnesses, and the specific immediate or long-term interventions implemented to protect residents from further abuse. In both incidents, the progress notes for the residents involved only briefly mentioned that a staff member reported an alleged physical altercation and that the residents were separated, with notifications made to the physician, POA, Ombudsman, and police. No further details about the incidents, the residents' conditions, or the investigative process were documented in the electronic medical records. The administrator confirmed that these brief progress notes were the only entries related to the altercations in the residents' records.