Failure to Investigate Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy by not initiating and thoroughly investigating an allegation of resident-to-resident verbal/mental abuse. One resident (R7), who has multiple medical conditions including blindness in the left eye, hypertension, diabetes with proliferative diabetic retinopathy, hyperlipidemia, and a history of falls, reported that another resident (R16) was harassing her. On observation, R7 was awake and alert in the dining room and stated that R16 came to her room, harassed her, told her he would get people to beat her up, and interfered with her wig. A nursing progress note dated 2/16/2026 by an LPN documented that R7 complained of being harassed by another resident, requested to be taken to her room, and reported hearing that other residents might attack her if she was seen in the dayroom. The note further described that R16 came to R7’s room, continued to bother and harass her despite being asked to leave, and that R7 was crying and called her family, who came to the facility, with the situation becoming intense. Interviews with involved parties provided differing accounts of the altercation but consistently indicated a conflict between the two residents that included alleged threats. R16 stated he recalled an altercation with R7, claiming he told her to stop messing with people, that she became rude and cursed at him, and that he cursed back. He denied threatening her but admitted telling R7 and her sister that if R7 put her hands on him first, he would do the same. A family member (V48) reported that R7 called her crying and said that R16 went to R7’s room, pushed the door open, and told R7 she better not come to the dining room or he would “f her up.” A CNA (V45) stated she was present on the unit but did not witness the incident; she answered a phone call from a very upset family member stating that R16 had said something to R7. An RN (V18) reported being called to the floor because R7’s family was present, and was informed that R7 said R16 came to her room and threatened her; V18 told the family the facility was going to investigate and notified the DON and the administrator. Despite these allegations and the facility’s written abuse policy, the administrator (V1), who is the abuse coordinator, did not initiate an investigation at the time of the incident. When the surveyor requested the investigation, V1 stated that he did not conduct any investigation because he did not consider the situation to be abuse, explaining that not every disagreement is abuse and giving his own example of what he considered verbal abuse. The facility’s abuse prevention and reporting policy, however, defines mental and verbal abuse to include harassing and threatening residents and specifies that resident-to-resident altercations should be reviewed as potential abuse and that all incidents will be documented and investigated when abuse, neglect, exploitation, mistreatment, or misappropriation is alleged or suspected. There was no documentation that anyone formally interviewed R7 or R16 regarding the incident, and V1 only documented speaking to R7 about moving her to another floor, demonstrating that the required internal investigation of the alleged resident-to-resident verbal/mental abuse was not carried out in accordance with facility policy.
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