Failure to Investigate Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate two separate resident-to-resident abuse incidents involving a resident with severe cognitive impairment and another resident with moderate impairment. On two occasions, one resident was observed standing over her roommate, exhibiting aggressive and threatening behavior, including yelling and causing the roommate to cry and express fear. Despite these incidents being documented in progress notes, there was no evidence in the clinical records that an investigation was initiated, nor was there documentation of notification to the affected resident's representative. Additionally, the clinical records did not show any actions taken to prevent recurrence of these incidents, such as offering to move the resident to a different room. Staff interviews confirmed that the facility did not complete an investigation into the incidents, as required by facility policy. The residents involved had significant medical histories, including dementia, heart failure, diabetes, and recent stroke, and both had their children listed as emergency contacts and responsible parties. The lack of investigation and follow-up was confirmed by the Director of Nursing during interviews.