Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an alleged verbal altercation between two residents, one of whom had a history of non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. The incident occurred in the dining room, where one resident used racial slurs, derogatory language, and threatened physical harm toward another resident, who then attempted to physically retaliate. Staff intervened and separated the residents, and no physical harm was reported. Despite the severity of the verbal altercation and the facility's policy requiring investigation and reporting of suspected abuse, the incident was not investigated or reported to the appropriate authorities. Interviews with the Unit Manager, DON, and ADON revealed that they did not consider the incident reportable or requiring further investigation, even though the facility's policy mandates reporting and investigation of all alleged abuse, including resident-to-resident incidents. The Administrator, upon review, agreed that the event was reportable, but no investigation or reporting had been initiated at the time of the survey.