Failure to Investigate and Report Alleged Threat of Harm
Penalty
Summary
The facility failed to conduct a thorough investigation and report findings to the State Survey Agency within 5 working days after a resident alleged that her roommate threatened to stab her. The incident involved a female resident with severe cognitive impairment, as indicated by a BIMS score of 03, and multiple diagnoses including Schizoaffective Disorder, Major Depressive Disorder, cerebral infarction, hemiplegia, and hemiparesis. Documentation showed that when the allegation was reported, staff spoke with the accused roommate, who denied the threat, and removed a back scratcher from the room, but no further investigation or safety assessments were completed. Interviews revealed that the resident who made the allegation moved herself out of the shared room to feel safe and reported her fear to staff. The Administrator acknowledged that no safe surveys were conducted and admitted that a more thorough investigation should have been completed, even though the allegation was not immediately substantiated. The facility's policy requires all allegations of abuse to be investigated and reported, but this process was not followed in this case.