Failure to Report and Investigate Resident-to-Resident Aggression as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation and reporting policy and to report a reasonable suspicion of a crime under Section 1150B of the Act after an aggressive resident-to-resident incident. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, that two nurses intervened and reported the incident to the DON, and that the NHA later stated he had watched video and believed the resident was only petting the other resident’s head. The complaint further alleged this resident-to-resident incident was not reported by the facility. The facility’s written policy required that all allegations or suspicions of abuse, including mistreatment and injuries of unknown source, be immediately addressed, that an Unusual Occurrence report be completed by the charge nurse, that the Administrator be notified, that an investigation be initiated within 24 hours, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. Resident 82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting for this resident documented aggression toward others, including an entry on 12/06/2025 at 17:00 stating that the resident, while getting ready to eat dinner and standing next to another resident, put his hands over her hair/eyes. LPN S, who documented this note, later reported that she was working at the time of the incident when the resident grabbed onto the other resident’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because this resident was known to have extremely aggressive behaviors such as hitting, punching, spitting, swinging, kicking, and reaching out toward others. LPN S stated that when the resident grabbed the other resident’s head, it was not gentle. Additional behavior charting for this resident on subsequent dates documented further aggressive behaviors, including raising fists in a threatening manner and following a female resident, placing a hand on her back and reaching toward her again, which upset the other resident. Resident 90, the other resident involved, was also admitted with Alzheimer’s disease and had a BIMS score of 0/15, indicating cognitive impairment. Her EMR progress notes over a several‑month period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation that the aggressive resident touched or grabbed her head on the date of the incident. Her record also indicated that she was elderly, blind, hard of hearing, and receiving hospice care. The NHA acknowledged in an interview that he was aware of a situation between these two residents about a month prior, that he did not report or investigate the occurrence because he felt it did not rise to the level of being reportable or needing investigation, and that he no longer had video footage of the occurrence. This combination of staff reports, behavior charting, and the NHA’s decision not to report or investigate, despite the facility’s abuse policy requirements, formed the basis of the cited deficiency.
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