Failure to Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency and the facility administrator after a verbal altercation occurred between a resident and a dietary aide. The resident, who was cognitively intact with a BIMS score of 15/15 and had diagnoses including schizophrenia, anxiety disorder, depression, and chronic pain syndrome, reported that he and a staff member engaged in a heated exchange involving yelling and name-calling over a request for two sandwiches. Another staff member intervened to de-escalate the situation, but neither staff member nor the resident reported the incident to facility management. Interviews revealed that both staff involved in the incident acknowledged the altercation and the use of inappropriate language, but did not notify management as required by facility policy. The administrator confirmed that leadership was unaware of the incident until it was brought to their attention during the survey. Facility policy mandates immediate reporting of any situation considered abuse or neglect, but this procedure was not followed in this case.