Failure to Notify Resident Representative After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to notify the representative of a resident following incidents of resident-to-resident abuse. Specifically, there were two documented occasions where one resident, who had a diagnosis of dementia and a BIMS score indicating severe cognitive impairment, was subjected to distressing behavior by her roommate, who also had dementia and exhibited behavioral symptoms such as combativeness and wandering. In both incidents, the roommate was observed standing over the resident, yelling and causing the resident to cry and express fear. Despite these events, there was no documentation in the resident's clinical record indicating that her representative was notified of the incidents. Review of facility policy and interviews confirmed that the facility's procedures require notification of a resident's representative in such situations. The Director of Nursing acknowledged that the required notifications were not made. The clinical records and progress notes for the affected resident did not contain any evidence of incident documentation or representative notification, which is inconsistent with both facility policy and regulatory requirements.