Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident abuse following an incident in which one resident hit another. On the day of the incident, a CNA reported that while preparing one resident for a shower, she heard the roommate yelling and upset, moved the resident into the hallway to prevent escalation, and notified the assigned nurse that the residents should be separated. After completing the shower and returning the resident to the room, the CNA observed the roommate get up from his bed and strike the resident in the back of the head with a closed fist, then called for help and staff separated the residents. The assigned nurse later confirmed he was told the residents were fighting and that the struck resident reported being hit in the back of the head, but he did not document the incident in either resident’s medical record because the ADON and DON were already present taking statements. The facility’s investigation was limited and did not capture key information about prior behaviors and conflicts between the two residents. The ADON confirmed that only two staff members were interviewed and that he asked the CNA only what happened and what she witnessed, without follow-up or clarifying questions, and he could not recall receiving formal training on taking statements or investigating abuse. Another CNA reported she had been told in morning report that the resident who later hit his roommate could become easily agitated, upset, and rude. A nurse reported that the two residents had a history of disagreements and arguments about lights and television volume at night, occurring a few times after they were roomed together, and that the resident who later hit his roommate was known to yell out for staff and be impatient; however, she did not document or report these prior arguments because she felt she had resolved them. The DON stated that when a nurse is notified of residents arguing, she expected the nurse to address it immediately to prevent escalation, and that it was her expectation that staff document and share all incidents between residents that could lead to abuse. Upon review of both residents’ medical records, the DON confirmed there was no documentation of previous disagreements between the two residents and no documented concerns with the aggressor’s behaviors, and she had no knowledge of any prior incidents between them. The DON was assigned by the previous Administrator to complete the abuse investigation and the five-day follow-up report to the State Agency, confirmed it was her first time fully completing an investigation, shared investigative duties with the ADON, and reported she had not been trained in how to complete an abuse investigation. The facility’s abuse policy required that suspected or alleged abuse be immediately reported, thoroughly investigated, and completely documented, with a verification of incident investigation report completed within five working days, but the investigation did not meet these standards and did not reveal several past incidents or provide a full picture of events leading to the abuse.
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