Failure to Report Resident-to-Resident Abuse Allegation Involving Threats and Weapon
Penalty
Summary
The facility failed to appropriately report an allegation of resident-to-resident abuse to the proper authorities as required by policy and regulation. A resident with multiple medical and psychiatric diagnoses, who was alert and oriented with minimal cognitive deficits, reported feeling threatened by another resident. The threats included statements about physical harm and the presence of a knife, which was subsequently found and removed by staff. Despite the resident expressing ongoing fear and the incident meeting the facility's criteria for a reportable event, the required notifications to authorities and creation of a self-reported incident were not completed. Documentation and interviews confirmed that staff, including the Activity Director and DON, were made aware of the incident and acknowledged it should have been reported. The facility's own policies define threatening gestures and fear as forms of abuse and require immediate reporting of suspected abuse. However, as of the time of review, there was no evidence that the incident had been reported to law enforcement or regulatory agencies, constituting a failure to follow established procedures for abuse reporting.