Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report two separate incidents of resident-to-resident physical abuse to law enforcement, as required by its own policy and federal regulations. In both incidents, one resident with dementia struck another resident, also with dementia, first with a cane and later with a broom, resulting in the second resident falling to the ground. Both residents were cognitively impaired, as indicated by their low BIMS scores. After each incident, assessments were completed and responsible parties, physicians, and families were notified, but there was no documentation that law enforcement was contacted. Facility policy mandates reporting any reasonable suspicion of a crime, including assault and battery, to law enforcement, regardless of the residents' cognitive status. Interviews with the DON and Administrator confirmed that law enforcement was not notified after either incident. The DON stated that police were not contacted due to the residents' dementia diagnoses and past experiences where law enforcement did not take action. The Administrator acknowledged that law enforcement should have been notified in both cases and was unaware that this had not occurred.