Failure to Interview Key Witness in Resident-to-Resident Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy and procedure by not thoroughly investigating an allegation of resident-to-resident physical abuse involving two residents. One resident, admitted with multiple right rib fractures, DM, and HTN, had an H&P indicating lack of capacity to understand and make decisions and an MDS showing moderately impaired cognitive skills. Progress notes and an SBAR documented that this resident reported another resident repeatedly entering his room, leading to an altercation in which he raised his walker in defense, lost his balance, hit the wall, and sustained a right forearm skin tear. The other resident, admitted with sequelae of cerebral infarction, generalized muscle weakness, and difficulty walking, had an H&P indicating capacity to make decisions but an MDS showing severely impaired cognitive skills, and his SBAR documented his account of a verbal altercation escalating when the first resident raised a front-wheel walker, resulting in him becoming tangled with the walker, being hit in the chest, and accidentally hitting the other resident in the face. Multiple staff accounts confirmed that an altercation occurred and that staff intervened. A housekeeper reported seeing the first resident holding his walker up in the air in front of the second resident and stated she separated them before the administrator entered the room. A CNA reported hearing the housekeeper scream for help, observing both residents trying to fight, seeing the first resident attempt to hit the second resident with his walker, and seeing the second resident with his right fist raised attempting to punch but not making contact. This CNA stated she remained in the room with the administrator, assisted the first resident to sit on the bed, and helped calm him. An RN later reported that when she responded to the room, the CNA was present beside the first resident, who was seated on the bed, and that she spoke with the first resident using the CNA as a translator. The facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy required that the individual conducting the investigation interview any witnesses to the incident and staff members on all shifts who had contact with the resident during the period of the alleged incident. The DON stated she was not aware that the CNA had responded to the incident and therefore did not initially interview the CNA or obtain a written statement, even though she had obtained statements from other staff including the housekeeper, RN, LVNs, and other CNAs. The DON acknowledged that the allegation between the two residents occurred on a specific date and that the CNA was not interviewed until several days later, that the abuse policy was not followed, and that it was important to interview all staff who were involved in the incident to verify what they observed.
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