Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
Staff failed to immediately report an episode of verbal abuse between two residents, as required by facility policy. One resident, who had diagnoses including dementia and Parkinson's disease and was cognitively impaired, was admitted to the facility and shared a room with another resident diagnosed with major depression and anxiety. During the night, the cognitively impaired resident became agitated and began yelling, prompting the roommate to threaten to strangle them. Staff present at the time separated the residents by moving the agitated resident to the lounge and monitored them for safety. Despite the clear verbal threat, staff did not immediately notify the Administrator or the Director of Nursing Services (DNS) as required. The charge nurse and nursing supervisor were aware of the incident but did not document the altercation in either resident's clinical record, nor did they request written statements from staff involved. The DNS was not informed of the incident until the following morning, more than seven hours after it occurred, and only learned of it during a routine arrival at the facility. Facility policy mandates that all allegations or observations of abuse be reported immediately to the Administrator and DNS, with subsequent notification to the physician and initiation of an immediate investigation. The incident should also have been reported to the state agency and local law enforcement within two hours. These steps were not followed, resulting in a delay in both internal and external reporting and investigation of the abuse allegation.