Failure to Timely Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, to the administrator and appropriate authorities, including local law enforcement. Specifically, an incident occurred in which a female resident with severe cognitive impairment and behavioral issues struck a male resident on the head twice. The male resident initially denied the incident but later admitted to being hit during the facility's investigation. The incident was not reported to local law enforcement as required by facility policy and state regulations. The male resident involved had a history of moderate cognitive impairment, dementia, and physical limitations, requiring assistance with activities of daily living. The female resident had severe cognitive impairment, hallucinations, delusions, and a documented history of aggressive behaviors. At the time of the incident, she was on one-to-one supervision and awaiting transfer to a psychiatric hospital due to escalating behavioral symptoms. The incident was eventually reported to the state agency, but not to local law enforcement, based on the male resident's expressed fear of legal repercussions due to his probation status. Interviews with facility staff, including the DON and Administrator, confirmed that the administrator was made aware of the incident two days after it occurred and initiated an investigation at that time. Both the DON and Administrator acknowledged that the facility's policy required reporting such incidents to both state and local authorities, but the administrator chose not to notify law enforcement, citing the resident's and his family's request. The facility's own policy and state law mandate immediate reporting of abuse allegations to all appropriate authorities, which was not followed in this case.