Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct an investigation after being made aware of a physical altercation between two residents. One resident, who had severe cognitive impairment and lacked decision-making capacity, was pushed by another resident with moderate cognitive impairment and the capacity to make decisions. The incident was witnessed by a CNA, who reported that the resident intentionally bumped her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. The CNA reported the event to an LVN, who then informed the ADON. Despite these reports, the ADON and the Administrator did not consider the incident to be abuse and did not initiate an investigation. The facility's policy requires prompt and complete investigation of all alleged violations of abuse, neglect, exploitation, or mistreatment. However, the Administrator acknowledged being notified of the incident but chose not to report it to the appropriate authorities or begin an investigation, as he did not consider it abuse. This lack of action resulted in the facility not determining the underlying issues between the two residents or resolving the situation, contrary to facility policy and regulatory requirements.