Failure to Timely Report and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and immediately report, within the required two-hour timeframe, an alleged abuse incident involving verbal and physical altercations between residents. On the morning of 6/5/2025, a resident with a history of aggressive behavior kicked another resident's wheelchair and engaged in a verbal altercation. Despite this incident being witnessed and reported internally, it was not reported to the appropriate external agencies as required by facility policy and state regulations. The Director of Nursing (DON) acknowledged that the incident was not reported because there was no physical injury, contrary to the policy that mandates reporting all alleged abuse regardless of injury. The resident involved in the altercations had a documented history of schizoaffective disorder, bipolar disorder, and anxiety, and was noted to lack capacity to make decisions. This resident had previously exhibited aggressive behavior, including hitting an LVN on 6/2/2025. Despite these prior incidents, the care plan did not include specific interventions for supervision or monitoring to address the resident's aggressive behavior. On 6/5/2025, after the initial altercation in the hallway, the same resident later struck another resident in the activity room during a BINGO game, again without having been placed on increased monitoring or supervision. Interviews with staff confirmed that the incidents were reported internally but not to the required external authorities within the mandated timeframe. Staff members, including the Activity Director, DON, and others, stated that the policy required immediate reporting of all alleged abuse, but this was not followed. The facility's own policy emphasized prevention, identification, and timely reporting of abuse, but these procedures were not adhered to, resulting in a failure to protect residents from further harm.