Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime as required by section 1150B of the Act. On the evening of 5/23/25, a CNA witnessed one resident strike another resident in the chest multiple times with an open hand. The resident who was struck was found lying on the ground, expressed fear, and cried after the incident. The following day, the resident confirmed feeling scared due to the incident. Both residents involved had severe cognitive impairment, with one having a legal guardian and the other an activated POA for healthcare decisions. Despite the facility's policy requiring immediate reporting of abuse to the Administrator and appropriate authorities, including local law enforcement, the investigation documentation did not show that law enforcement was notified of the incident. The DON confirmed during an interview that the event was considered abuse and acknowledged that law enforcement had not been contacted.