Incomplete Documentation of Abuse Investigation After Staff Verbal Altercation Witnessed by Resident
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough abuse investigation after a resident with Down Syndrome witnessed a verbal altercation between two staff members. The incident report, dated 12/27/25, indicated that the resident observed a verbal disagreement between a QMA and a CNA at the nurses’ station. The facility’s Abuse Prevention Program policy required the charge nurse to complete an incident report and obtain written, signed, and dated statements from the person reporting the incident and from any witnesses, with completed copies provided to the Administrator or person in charge within 24 hours of the incident. Record review and interviews showed that the investigation file contained an incident report and a written statement from the QMA, but did not contain a written statement from the CNA involved in the argument. The ED stated there was no written statement from the CNA and that the CNA had been interviewed verbally with the weekend supervisor, but the interview was not documented. In contrast, the CNA reported that she had written a statement on the date of the incident and given it to the ED, and described the argument as starting over her refusal to serve regular-consistency food to residents on mechanically altered diets. The ED later indicated the CNA’s statement had been taken over the phone and maintained that no written statement had been provided, resulting in incomplete documentation of the abuse investigation in violation of facility policy and state regulation 410 IAC 16.3.1-28(d).
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.