Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse as required by regulation. A resident with a history of dementia, depression, and insomnia, but with intact cognition and judgment, reported being struck multiple times by another resident using a walking stick. The resident expressed distress over not being informed about the incident's consequences and stated a desire for police involvement. Documentation in the progress notes indicated the resident's complaint but did not identify the alleged perpetrator or document any monitoring of the involved residents. The social worker followed up with the resident but did not notify the physician, family, state agency, or law enforcement about the allegation. Interviews with facility staff revealed that the social worker did not report the abuse allegation to the administrator or appropriate authorities. The DON, after interviewing the alleged perpetrator, determined the abuse was unlikely and did not report the incident to the State Survey Agency, despite acknowledging that all abuse allegations are required to be reported. There was no evidence of required notifications or investigations being conducted or documented as per regulatory requirements.