Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of resident-to-resident abuse to the State Agency, specifically when one resident with severe cognitive impairment and a history of problematic behaviors, including verbal and physical aggression, verbally assaulted another resident and exhibited physical aggression toward an unknown resident. Documentation in the medical record showed repeated incidents where the resident yelled, hit, and threw objects at staff and other residents, and was unable to be redirected despite multiple interventions. Progress notes and psychiatric evaluations indicated that these behaviors were ongoing and included both verbal and physical aggression almost daily. One resident, who had moderate cognitive impairment and a history of anxiety and depressive disorder, expressed fear for his safety due to his roommate's violent behavior. Staff documented that this resident was afraid because his roommate was yelling, cursing, and threatening him, and that the roommate had previously hit staff and other residents. The roommate was eventually moved to a private room, but there was no evidence that the incident was reported as required, nor that a thorough investigation was conducted. Interviews with staff, including LPNs, the DON, and the Social Worker Director, revealed that the incident was discussed internally but not reported to the Administrator or the State Agency. The facility's own policy required that resident-to-resident altercations be reviewed as potential abuse situations and that such incidents be reported. However, review of self-reported incidents showed no reports were made for the alleged events, and not all potentially affected residents were interviewed. The Social Worker Director also failed to document an interview with the resident who expressed fear, believing it was not important.