Failure to Investigate and Intervene After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions following multiple resident-to-resident abuse incidents involving a resident with a history of aggressive behaviors. Clinical record review showed that this resident exhibited daily physical and verbal aggression, as well as daily rejection of care, and had diagnoses including depression, anxiety, PTSD, and bipolar disorder. Despite documented altercations with other residents on several occasions, the facility did not conduct comprehensive resident and staff interviews for the dates of the incidents to determine the extent of the allegations or whether other residents were affected. Additionally, the care plan lacked specific direction for staff to report and address resident-to-resident altercations after these incidents occurred. Facility documentation revealed that while some incidents were recorded and immediate actions such as separating residents and monitoring were taken, there was a lack of a complete investigation for at least one incident, and the care plan was not updated to include interventions to prevent further occurrences. The facility's policy required thorough investigation and reporting of all alleged violations, but this was not consistently followed, as evidenced by missing investigation summaries and incomplete follow-up after the incidents.