Failure to Conduct Thorough Investigation After Resident Behavioral Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who exhibited heightened behaviors, including refusing medication, throwing objects, attempting to pull the fire alarm, making verbal threats, and having physical contact with aides. The resident, who was cognitively intact, also obtained a butterknife from a meal tray, threatened staff and another resident, and struck a window with the utensil. Despite these actions and the facility's policy requiring a comprehensive investigation of all allegations of abuse, neglect, or mistreatment—including resident and staff interviews and documentation in the electronic incident report system—no incident report was filed, and the event was not documented in the Accident and Injury log. The administrator acknowledged that while staff were asked to provide witness statements, no residents were interviewed or asked for statements, and there was no documented evaluation to determine if the other resident involved felt safe. Additionally, monitoring of the potentially affected resident for harm did not occur. The administrator admitted that a full investigation, as outlined in facility policy and regulatory requirements, was not completed.