Failure to Report Alleged Abuse and Threats Between Roommates
Penalty
Summary
The facility failed to follow its 'Abuse and Neglect' policy by not reporting an allegation of abuse involving a resident with schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder. This resident alleged that their roommate, who also had significant psychiatric diagnoses and behavioral issues, had threatened to hit them, requested money, and took their debit card. The resident reported these threats and theft to staff, stating that the threats had persisted for several days. Despite these allegations, the staff did not report the incident to the abuse coordinator or the appropriate authorities as required by facility policy. Multiple staff members were aware of the situation, with some reporting the behavior to other staff but not escalating it to the designated abuse coordinator or administrator. Interviews revealed confusion and lack of communication among staff regarding the reporting process. The nurse who was informed of the threats relayed the information to the social worker, who in turn did not report it to the abuse coordinator. The social worker and restorative nurse both stated they were not made aware of any abuse allegations, and the director of nursing and assistant administrator confirmed they were not informed until the surveyor brought it to their attention. The facility's policy clearly states that all allegations or suspicions of abuse must be reported immediately to the administrator or their designee, which did not occur in this case.