F0610

D

Failure to Investigate and Protect Residents After Alleged Resident-to-Resident Abuse

Edgerton, Wisconsin Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and respond to an alleged resident-to-resident altercation and to implement measures to prevent further incidents. Facility policy on Abuse, Neglect and Exploitation requires immediate investigation of any suspicion or report of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, determining whether abuse occurred, and documenting the investigation. The policy also requires actions to protect residents during and after an investigation, such as examining the alleged victim for injury, increasing supervision, providing emotional support, and revising the care plan. Despite these written procedures, the facility did not follow them after being informed that one resident allegedly slapped another resident’s face.

The incident in question occurred when a CNA was informed by another resident that one resident had slapped a second resident across the face. The CNA did not witness the event but immediately separated the two residents and reported the incident to an LPN. The LPN reported that she assessed the alleged victim for red marks, separated the residents, and notified the ADON, who instructed her to keep the residents separated and to keep an eye on them. The LPN stated she did not complete any further assessment, such as vital signs, and did not document the incident. She also indicated she was not aware of any interventions put in place to prevent recurrence and that nothing was added to the 24-hour board or passed through in report on her next shift. Multiple CNAs reported that the resident alleged to have slapped others had a history of paranoia, delusions, and verbal and physical aggression toward staff and residents, including prior incidents of hitting another resident.

The Nursing Home Administrator acknowledged that staff had verbally reported that a resident witnessed the alleged slap, but there was no documentation of the incident or any investigation. The Administrator stated she spoke with the resident witness, who described the contact as light tapping on the face and reported that the residents’ wheelchairs had become hung up, with no words exchanged. Based on this conversation, no further action was taken: the Administrator did not interview the CNA or LPN who reported the incident, did not interview other residents for safety concerns, did not conduct or document an investigation, and did not follow up with the two residents involved. The Administrator acknowledged that a resident-to-resident altercation should be investigated, that this incident could have been potentially reportable to the state, and that there should have been documentation, but none of these required steps occurred. As a result, the facility did not ensure that all alleged violations were thoroughly investigated or that steps were taken to protect residents and prevent further abuse or altercations.

The resident alleged to have initiated the contact had significant cognitive impairment, with a BIMS score of 02 on a recent MDS Significant Change Assessment, and diagnoses including paranoid schizophrenia and severe unspecified dementia with mood disturbance. Staff interviews described this resident as verbally and physically aggressive with staff and residents, and as having a prior altercation with another resident. Despite these known behaviors and the facility’s own policy requiring identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, there was no evidence that the incident led to any new interventions, care plan revisions, or enhanced supervision. CNAs responsible for updating care guidance sheets confirmed that no new interventions were communicated or added following the incident. This pattern of inaction and lack of documentation demonstrates that the facility did not follow its abuse prohibition plan or investigative procedures in response to the alleged resident-to-resident abuse.

The facility also failed to ensure the health and safety protections outlined in its policy during and after the alleged incident. There was no documented physical or psychosocial assessment of either resident beyond a brief visual check for red marks on the alleged victim. There was no evidence of increased supervision, emotional support, or counseling for the residents involved, and no revision of the care plan to address the behaviors and prevent recurrence. The Administrator confirmed that the matter remained at the level of informal conversation without formal follow-up. Consequently, the facility did not meet its own standards for immediate investigation, thorough documentation, and protective measures in response to an allegation of abuse, neglect, exploitation, or mistreatment.