Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an alleged verbal altercation between two residents to Adult Protective Services and the Department of Health and Human Services within the required timeframe. The incident involved a resident with moderate cognitive impairment, non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. During the altercation, another resident used racial slurs, derogatory language, and made threats, prompting the affected resident to attempt to physically respond before staff intervened. No physical harm occurred, but the resident who was verbally abused reported feeling shocked and unsafe as a result of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, interviews with the Unit Manager, DON, and ADON revealed that they did not consider the verbal remarks or the situation to be reportable and did not initiate an investigation or report the incident. The Administrator, upon review, agreed that the event was reportable, but this determination was made after the fact, indicating a failure to follow established reporting protocols.