Failure to Investigate Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify a resident-to-resident altercation as potential abuse and to initiate an investigation as required by its abuse, neglect, and exploitation policy. One resident, who had diagnoses of dementia with behaviors, Alzheimer’s disease, major depressive disorder, and anxiety, was care planned for disruptive and potentially physically aggressive behaviors toward other residents and staff. Her care plan directed staff to use non-pharmacological interventions, assess for unmet needs, and review behaviors regularly. Despite this, nursing documentation on one occasion recorded that she was involved in a resident-to-resident altercation in which she grabbed another resident’s arm and covered the other resident’s mouth, requiring redirection and physical removal of her hands. The nurse’s note from that incident stated that the resident was removed from the area and provided one-on-one interaction to calm her, and that staff would continue to monitor for safety due to poor safety awareness. However, the facility was unable to provide evidence that a thorough investigation of this altercation was conducted. There was no documentation of an incident report, no documented assessment of injuries, and no collected witness statements related to the event, despite the description of physical contact between residents. Administrative staff later reported that the documenting nurse was new and had been trained by another nurse, and that the incident was not reported to administration at the time because the training nurse did not feel it was abuse. The facility’s written Abuse, Neglect, and Exploitation policy required that all individuals report allegations or suspicions of abuse, including abuse by other residents, immediately to the Administrator or supervisor. The policy further required the Administrator or designee to assess the resident, document injuries, complete an incident report, notify the physician and family, interview involved parties and witnesses, and report to the State agency and law enforcement within specified time frames when there is reasonable suspicion of a crime. In this case, despite a documented resident-to-resident altercation involving physical contact, these required reporting and investigative steps were not initiated or carried out, resulting in the failure to recognize and treat the event as a potential abuse incident in accordance with facility policy and regulatory expectations.
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