Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to facility policy, all involved persons, including witnesses, should be identified and interviewed, and complete documentation of the investigation should be maintained. However, the investigation did not include interviews or documentation from key witnesses who were present during the incident, such as two other residents and staff members who observed the altercation. The incident in question involved one resident hitting another on the shoulder, followed by a physical response. Both residents involved had intact cognition as indicated by their BIMS scores, and neither exhibited behavioral symptoms during their respective assessment periods. The event was reported promptly to the state survey agency, and staff separated the residents at the time of the incident. Despite this, the facility's investigative documents lacked statements or interviews from the witnesses who were present, including two residents with intact cognition and staff who directly observed the event. Interviews with facility staff revealed that the social services director and the director of nursing were unaware that other residents had witnessed the incident, and there was no documentation of interviews with the staff members who responded to the event. The administrator confirmed that all present during the incident should have been interviewed, but the investigation records did not reflect this. As a result, the facility did not meet its own policy requirements for a complete and thorough investigation of the abuse allegation.