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F0609
D

Failure to Report Resident-to-Resident Physical Abuse to Law Enforcement

Honolulu, Hawaii Survey Completed on 04-25-2025

Penalty

Fine: $27,885
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of resident-to-resident physical abuse to law enforcement in three separate incidents, despite its own policy requiring such reports for any reasonable suspicion of a crime, including assault and battery. In each case, the facility deferred to the wishes of the residents or their families, who declined to involve law enforcement, even though the incidents involved physical altercations. For example, one incident involved a resident with a history of physical aggressiveness assaulting another resident, and another involved two residents physically assaulting each other. In a third case, a resident punched another after a verbal altercation, and the family of the victim declined to pursue charges or contact the police. Interviews with facility leadership, including the Administrator and DON, confirmed that law enforcement was not notified in any of these cases because the residents or their families did not want police involvement. The facility's actions were inconsistent with its policy, which mandates reporting all reportable incidents to law enforcement regardless of resident or family preference. These failures were identified during a State Agency investigation and were documented in the facility's records and staff interviews.

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