Failure to Report Resident-to-Resident Abuse to Authorities
Penalty
Summary
The facility failed to ensure that multiple incidents of verbal and physical abuse between residents were reported to the State Agency (SA) and Adult Protective Services (APS) as required by both regulation and facility policy. Documentation and interviews revealed that one resident with severe cognitive impairment was repeatedly subjected to verbal aggression, threats, and physical abuse by another resident with a history of behavioral disturbances, including paranoia and anger. Despite staff witnessing these incidents and documenting them in clinical records, there was no evidence that the required reports were made to the appropriate authorities. Staff interviews indicated that several team members, including CNAs and LPNs, observed or were informed of incidents where one resident yelled at, threatened, and physically assaulted another resident. In one instance, staff witnessed a resident being slapped, resulting in visible injury, and this was reported internally to facility management. However, management instructed staff not to escalate or report the incident externally, citing the cognitive status of the residents involved. The facility's Assistant Director of Nursing and other staff confirmed that they did not report the abuse to the SA or APS, believing it was the responsibility of the administrator, who in turn determined the incident was not reportable if the victim could not recall the event. The facility's own policy required immediate reporting of all alleged violations to the administrator, state agency, and APS, with specific timeframes for reporting based on the severity of the incident. Despite this, there was a consistent pattern of internal reporting without external notification, even in cases involving physical harm and repeated verbal abuse. Documentation also showed that family members were informed of some incidents, and staff were later provided with abuse education, but the required notifications to authorities were not made as stipulated by policy and regulation.