Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to law enforcement as required by its own policy and regulatory standards. A cognitively intact resident with multiple medical conditions, including morbid obesity, nontraumatic intracerebral hemorrhage, above-knee amputation, congestive heart failure, and gout, reported that another resident entered his room during the night, sat on his bed, and struck him multiple times in the chest. The resident expressed emotional distress, including feeling unsafe and experiencing flashbacks, and stated that no one followed up with him after the incident to discuss what happened or how he felt. Facility documentation, including nurses' notes and an incident report, confirmed that the event was reported internally to the Administrator and the responsible party, but there was no documentation that law enforcement was notified. The facility's policy requires reporting all alleged violations to law enforcement when applicable, but this step was omitted. The Administrator interviewed after the incident acknowledged that law enforcement should have been contacted in this case.