Failure to Report Resident Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving three residents to local law enforcement, as required by its own abuse, neglect, and exploitation policy. The incident involved verbal threats of physical harm among residents during a smoking break, with one resident making explicit threats to set another on fire and have them shot, and another resident responding with threats of physical violence. Staff intervened by separating the residents and placing two of them on one-to-one observation for the duration of the investigation. The incident was reported to the state agency, but there was no documentation that law enforcement was notified, despite the facility's policy stating that law enforcement should be contacted when applicable. Resident assessments indicated that all three residents involved had intact cognition, with relevant diagnoses including depression, anxiety disorder, schizophrenia, heart failure, hypertension, aphasia, parkinsonism, and a history of traumatic brain injury. During the incident, one resident retrieved a small knife from their purse and attempted to jab a nurse while simultaneously handing over the knife, after being informed that possessing a knife on the property was illegal. This resident was subsequently sent out for a psychiatric evaluation due to continued aggressive and violent behavior, as documented in behavioral health hospital records. Interviews with staff and the administrator confirmed that the residents were separated and placed on one-to-one observation, and that the incident was reported internally and to the state agency. However, the administrator stated that law enforcement would only be notified if a resident agreed to it, and could not provide documentation that residents declined law enforcement involvement. Staff accounts corroborated the sequence of events, including the verbal threats and the incident involving the knife. The lack of notification to law enforcement constituted a failure to follow the facility's abuse reporting policy.