Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough abuse investigations for multiple resident-to-resident incidents as required by its own Abuse, Neglect and Exploitation policy. For one incident, the facility’s Incident Online Submission Form documented that one resident attempted to propel himself around another resident who did not move, then grabbed the other resident’s wheelchair handles and pulled him back, causing the resident to fall to the ground and sustain a skin tear on his right elbow. Although the facility initiated an investigation that included staff and resident interviews, the questioning of staff was limited to whether they had ever witnessed the resident redirecting other residents in wheelchairs, rather than asking if they had ever seen him attempt to hurt other residents. In an interview, the Administrator confirmed that the investigation into this resident-to-resident incident was incomplete because staff were not asked about possible abuse. In a separate incident, a progress note documented that CNA staff reported a resident with a history of traumatic brain injury and dementia with agitation had attempted to enter the rooms of two unnamed female residents, with one female resident reporting that he tried to get into bed with her and stating she would call 911 if the behavior recurred. The note indicated no injuries were observed and both residents were within normal limits on assessment, and the DON was notified with a room change recommended. However, this incident was not entered on the facility’s Incident and Accident Report Log, and there was no documentation in facility or resident records that any investigation of potential abuse was initiated or completed related to this event. The Administrator and DON confirmed that an investigation of potential abuse was expected for any such incident, including this potential resident-to-resident abuse, but none was documented, contrary to the facility’s policy requiring interviews of the resident, the accused, and all potential witnesses and, if needed, expanded interviews when there are no direct witnesses.
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