F0610

D

Failure to Thoroughly Investigate and Timely Report Resident-to-Resident Altercations

Beaver Dam, Wisconsin Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and timely report multiple resident-to-resident altercations, as required by its abuse/neglect/exploitation policies and state reporting requirements. The facility’s written policy required identification of staff responsible for investigations, interviews of all involved persons and others who might have knowledge, and complete and thorough documentation of the investigation, including submission of a final report to the state agency within five working days. The separate investigation procedure policy did not contain information on how to conduct and document a thorough investigation. For the altercation in which one resident in a wheelchair slapped another resident in the head/face three times in the dining room, the facility’s investigation file contained only the initial abuse report to the state, the misconduct incident report, and a two‑page investigation report. The investigation report stated that all staff working at the time were interviewed and that skin checks were completed on both involved residents and all other residents on the unit, but the facility could not produce documentation of these staff interviews or the additional residents’ skin checks.

In this first altercation, the resident who slapped another had dementia with agitation and a BIMS score indicating moderate cognitive impairment, and the resident who was slapped had severe cognitive impairment and behavioral symptoms directed toward others. The incident report documented that the aggressor rolled up to the other resident and slapped him three times without saying anything, and that both residents were separated and assessed for injury. Staff witnesses, including a medication technician and a CNA, reported seeing the incident and removing the aggressor, but later interviews revealed they did not recall being asked for follow‑up witness statements beyond the initial incident documentation. The DON stated that investigations for resident‑to‑resident altercations should include interviews with all residents involved and all staff working that day, with all interviews documented, and that skin assessments should have been completed on other residents on the hall. However, the DON reported he had not done any skin assessments following this incident, and the administrator later verified that the skin assessments on other residents described in the investigation summary had not been completed and that only staff who directly witnessed the incident were interviewed. Angel Rounds documentation produced by the administrator showed only general observations such as appearance, clothing changes, concerns voiced, and room cleanliness, with no documentation that residents were asked if they felt safe or had witnessed abuse.

The facility also failed to thoroughly investigate and timely report a separate resident‑to‑resident threat and a later physical altercation between two other residents. One resident with a history of traumatic brain injury, vascular dementia, severe cognitive impairment, and documented behavioral issues including yelling, cursing, and aggression toward others was care planned for triggers such as perceived rudeness to staff and instructed interventions including separation from altercations and one‑to‑one supervision when aggressive. Another resident, with intact cognition and behavioral issues including yelling, cursing, blocking hallways, and following staff, reported that the first resident walked up to him and said, “I’ll slap you in your face right now,” then walked away; this incident was not witnessed by staff. The initial abuse report and misconduct incident report stated that staff and resident interviews were conducted, and the investigation report asserted that all staff working during the time of the incident and any available residents were interviewed, but subsequent review showed there were no staff or additional resident interviews documented for this allegation. An additional untitled document described a later incident in which the same aggressive resident approached the same other resident in the dining room and struck him; staff were present but did not directly witness the strike, and the document stated that a comprehensive investigation with staff and resident interviews was conducted, yet the facility’s investigation file contained only one staff interview. The administrator and corporate nurse confirmed that the required five‑day follow‑up reports for both the October 3 and October 4 incidents were submitted to the state agency seven days late, and the administrator acknowledged he did not interview all staff and residents as required and had no documentation of many of the interviews he stated were done.