Failure to Report and Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
Facility staff failed to identify and report a resident-to-resident altercation as potential abuse in accordance with facility policy and regulatory requirements. One resident involved, R62, had diagnoses including dementia with behaviors, Alzheimer's disease, major depressive disorder, and anxiety, with a Quarterly MDS indicating severely impaired cognitive function and dependence on staff for most ADLs. Her care plan documented a history of disruptive and combative behaviors, including potential physical aggression toward other residents and staff, and directed staff to use non-pharmacological interventions and assess for unmet needs when behaviors occurred. Nurse's notes dated 09/04/25 at 2:26 PM documented that R62 was involved in a resident-to-resident altercation in which she was observed grabbing another resident's arm and covering the other resident's mouth. The note indicated that R62 required redirection and physical removal of her hands, after which she was removed from the area and provided 1:1 interaction with a nurse to calm her, with staff to continue monitoring for safety due to poor safety awareness. Despite this documentation of physical contact and an altercation between residents, the facility did not initiate an investigation into the incident. The facility was unable to provide evidence that the incident was reported to the Administrator or to the State Survey Agency as required by its Abuse, Neglect, and Exploitation policy. That policy requires all individuals to immediately report allegations or suspicions of abuse, including abuse by other residents, to the Administrator or supervisor, and requires the Administrator or designee to assess the resident, complete an incident report, gather witness statements, and report to the State agency and law enforcement as indicated. Interviews with administrative nursing staff revealed that the nurse who documented the incident was new, and the training nurse did not consider the event to be abuse and therefore did not report it to administration, resulting in no timely reporting or investigation of the altercation as potential abuse.
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.