Failure to Identify, Investigate, and Report Resident-to-Resident Abuse and Update Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, protect, and report an incident of resident-to-resident abuse, and to implement care plan interventions afterward. One resident reported severe left shoulder pain that began after another resident suddenly charged at him, grabbed him from behind, and placed both arms around his upper torso in a headlock. During observation, the resident was seen in bed holding his left shoulder and wincing in pain, and later verbalized psychosocial distress related to the incident. The Administrator/Abuse Coordinator acknowledged reviewing security camera footage the night of the incident, which showed the aggressor resident approaching from behind and placing both arms around the other resident’s upper torso. Despite this, the Administrator did not consider the event to meet the facility’s definition of abuse at that time and did not report it to the state agency until nine days later, contrary to the facility’s policy requiring immediate or timely reporting of allegations and incidents. The facility did not conduct an internal investigation of the incident in a timely manner and was unable to provide staff statements, interviews, incident reports, or other related documentation during the survey. Review of the injured resident’s EMR showed no new care plan interventions or protective measures were initiated following the incident to address his severe shoulder pain or psychosocial distress, and his care plan was not updated until during the survey. The other resident involved had diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder, yet his care plan was also not updated after the incident. Care plan sections addressing abuse, behaviors, mood triggers, and physical and verbal aggression for both residents were only added during the survey, indicating that the facility did not promptly implement or document interventions or protections following the reported abuse, as required by its Abuse and Retaliation Prevention and Reporting policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.