Failure to Notify Physicians Following Allegation of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ physicians of an allegation of abuse as required by its Abuse Prevention Program Policy. One cognitively intact resident, R12, with diagnoses including osteoarthritis, hypertension, and psychosis, alleged on 11/04/2025 that another resident, R5, struck her in the face while she was exiting a public restroom on the second floor. A nurse on duty (V11, RN/Infection Preventionist) heard R12 say “don’t hit me,” found R12 near the nurse’s station and R5 by the bathroom door, and confirmed with R12 that she had been hit in the face. The facility’s Final Incident Investigation Report later documented that the allegation of abuse was substantiated and stated that the resident’s physician was made aware of the allegation and that R5 was sent to the hospital for evaluation per physician orders. Interviews and record review, however, showed that the required physician notifications were not completed or documented. V11 stated that she informed the Administrator (V1) that she was too busy to complete the abuse protocol and that V1 instructed LPN V14 to complete it, which included calling the family and physician for both the alleged victim and perpetrator. V11 acknowledged she did not call the family or physician for either resident. V14 stated she did not receive instructions from V1 to complete the abuse protocol and did not call the family or physician for either resident. Review of the electronic health record revealed no documentation that the physicians or psychiatrist were notified regarding the allegation involving R12 and R5, despite the facility policy requiring that physicians be notified of any incident and that the resident’s representative and physician be notified of the alleged incident and investigation. Further interviews confirmed that no psychiatrist notification occurred following R12’s allegation that R5 hit her. The Psychiatric Rehabilitation Services Director (V12) stated that when a resident makes an allegation of physical abuse, the psychiatrist should be called, and that if the nurse had called, it should have been documented in the electronic health record; V12 later confirmed that no psychiatrist notification was done. The Administrator (V1) stated that any time a resident is struck by another resident, the abuse protocol must be initiated immediately, including separating the residents, placing them on behavior monitoring, and notifying the physician and emergency contact person, and that if notification of the doctor is not documented, it means it did not happen. V1’s review of the reportable and census records also showed that, contrary to the written report, R5 was not sent to the hospital on the date of the incident, further evidencing that the physician notification and related orders described in the report did not occur. These findings demonstrate the facility’s failure to follow its own abuse protocol and policy requiring physician notification for incidents of alleged abuse.
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