Failure to Thoroughly Investigate Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse involving one cognitively intact resident and one severely cognitively impaired resident. The cognitively intact resident had an admission history dating back several years and a recent BIMS score of 13/15, indicating intact cognition. A progress note documented that this resident struck another resident with an open hand. The other resident, who had severe cognitive impairment with a BIMS score of 4/15, was documented as standing next to the first resident’s bedside and attempting to calm the resident when the slap to the cheek occurred. Internal risk management notes described that the cognitively intact resident hit the cognitively impaired resident in the face with the back of the hand while the latter was trying to comfort the former, and that the incident was determined by the facility not to be state reportable. The cognitively impaired resident was assessed for injury, with none noted, and the DON was notified. During interview, the DON acknowledged there was no documentation of resident and staff interviews included in the investigation. This was inconsistent with the facility’s Abuse, Neglect, Exploitation policy, which required that all allegations and incidents be investigated with a focus on whether abuse or neglect occurred, the extent of any occurrence, clinical evaluation for signs of injury, causative factors, and interventions to prevent further injury.
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