Failure to Timely Report Resident-to-Resident and Resident-to-Staff Abuse
Penalty
Summary
The facility failed to immediately report two separate incidents involving abuse and physical altercations between residents and a staff member. On the morning of 5/3/2025, one resident verbally abused another by yelling profanity, then physically pushed the other resident's wheelchair, spun him around, and grabbed his jacket. Multiple staff members and a housekeeper witnessed the incident, and the affected resident reported feeling upset, sad, and discouraged. Despite being reported to the charge nurse and witnessed by several staff, the incident was not reported to the abuse coordinator, ombudsman, police, or the state health department as required by facility policy. Later the same day, the same resident attacked a Certified Nurse Assistant (CNA) by choking her in another resident's room. This incident was witnessed by a family member, who intervened and reported the event to facility leadership. The police were called, and the resident was transferred to a general acute care hospital under a 5150 psychiatric hold. The facility's progress notes documented the physical aggression, but the incident was not reported to the appropriate authorities within the required timeframe. Interviews with staff, including CNAs, LVNs, and the Director of Nursing, confirmed that both incidents met the facility's criteria for abuse and should have been reported immediately, but were not. The facility's policies require all allegations of abuse or mistreatment to be reported promptly, no later than two hours if abuse is involved. The failure to report these incidents resulted in emotional distress for the affected resident and had the potential for recurrence and harm to other residents and staff.