Failure to Thoroughly Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident physical abuse as required by its Abuse and Retaliation Policy Prevention Program. The policy dated 1/2026 states that any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation, and that the appointed investigator will at a minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable, as well as review written statements and pertinent records. On 1/2/26, an RN documented hearing yelling from the middle hall and then observing one resident wheeling out of another resident’s room. The second resident reported that the first resident allegedly crawled on top of her in bed and punched her on the right side of the face three times, after which she punched him back and pushed him off. The RN’s note also documented that the first resident was sent to the ED for psychiatric treatment due to increased agitation, and ED records indicated EMS reported that this resident had allegedly hit another resident earlier that day. The second resident’s progress note from the same date documented her report that a male resident allegedly crawled on top of her and punched her three times on the right side of her face, with an assessment showing no visible injuries or redness and no complaints of pain or distress. However, the abuse investigations and witness statements for both residents, dated 1/2/26 through 1/6/26 and signed by the Administrator, only included two statements from the RN and the roommate of the second resident and did not document that the first resident crawled on top of the second resident, hit her, or that she hit him back. In interview, the Administrator stated she did not know that the residents had hit each other, acknowledged she only had interviews from the RN and the roommate, and confirmed she did not interview other staff or residents who might have knowledge of the incident. The RN stated she had immediately reported to the Administrator that the second resident said the first resident was on top of her in bed and hit her in the head, and that she had hit him back. The investigation therefore did not capture or reflect the full allegation of mutual hitting and did not meet the facility’s own minimum investigative procedures.
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