Failure to Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Retaliation Prevention and Reporting Policy by not investigating an allegation of resident-to-resident physical abuse. One resident (R1) reported that another resident (R2) pushed him out of his wheelchair in the dining room, with no staff present, and stated he felt bad that someone attacked him in his place of residence. R1 said he asked a nurse to call the police and reported the incident to the Administrator (V1) later that morning. On the same day, R2 told staff that R1 got in his face and that he pushed R1, and a nurse (V9) recognized this as an abuse allegation per facility protocol, immediately notifying the Administrator. Despite this, the Administrator stated she was unaware that R2 had pushed R1 and believed the situation to be only a behavioral event. The Social Service Director (V18) reported that he was notified by the Administrator early that morning that there had been an altercation between the two residents, and that he and the Administrator reviewed dining room camera footage. The behavioral progress note he entered described R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. The camera view was partially blocked, and they could not verify whether R1 fell from his wheelchair. The Director of Nursing (V2) also received a text from the Administrator stating that R2 allegedly pushed R1 because R1 was yelling at him, but V2 was not involved in any investigation. Video footage later reviewed by surveyors showed R2 pacing in the dining room, then moving toward R1 in a threatening manner and forcefully pushing him with two flat hands, with the view of R1 partially blocked so it was unclear if he fell. The Administrator acknowledged that the push was forceful and constituted abuse of R1. However, no abuse investigation or grievance report was initiated at the time of the incident, and the Administrator stated she did not complete an investigation because she considered it only a behavioral event. The facility’s written policy required that all incidents involving alleged or suspected abuse be documented and result in an investigation, but this was not done until more than a day later, after surveyors were informed by R1 that he had been pushed out of his wheelchair by R2.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.