Failure to Timely Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse between two residents and did not report the results of the investigation to the state survey agency within the required five-day timeframe, as outlined in the facility's policy. The incident involved two residents, who were married but roomed separately, and escalated from a verbal argument to a physical altercation over a television. Both residents reported being struck by the other, and law enforcement was notified, resulting in one resident being detained and escorted out of the facility by sheriffs. Medical records and progress notes indicated that both residents had significant medical and psychiatric histories, including schizoaffective disorder, psychosis, bipolar disorder, cerebral infarction, and COPD. Documentation showed that the altercation was reported to the DON and law enforcement, and that the residents were separated following the incident. However, the facility's initial five-day report was submitted 15 days after the incident and lacked witness interviews, contrary to policy requirements. Subsequent investigation revealed that the wrong resident was initially identified as a witness, and the actual witness was not interviewed until after the state agency began its investigation. The DON was unaware of the revised report and the correct witness information prior to its submission to the state. The facility's policy required timely and thorough investigation, including interviews with all witnesses and documentation of findings, which was not followed in this case.