Failure to Report Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to report an incident of physical abuse involving two residents to the state agency and law enforcement, as required by its own Abuse and Neglect Policy. The incident occurred when one resident accused another of stealing money, leading to a verbal altercation that escalated into physical violence. Despite staff intervention, the aggressor grabbed the other resident by the hair, pulled them to the ground, and struck them in the side, resulting in visible injuries including a large hematoma on the head and bruising on the hip. The injured resident was subsequently sent to the emergency room for evaluation and treatment of a closed head injury. The resident who was assaulted had a complex medical and psychiatric history, including watershed brain damage, bipolar disorder, anxiety, impulse control disorder, and borderline intellectual functioning. At the time of the incident, the resident was cognitively intact but required supervision for activities of daily living and had a history of behavioral challenges. Documentation and interviews confirmed the sequence of events, the injuries sustained, and the involvement of staff who witnessed and attempted to intervene in the altercation. Despite clear evidence of physical abuse resulting in injury, the facility's administrative staff, including the Assistant Administrator and Administrator, chose not to report the incident to the state agency or law enforcement. They determined that the event did not constitute abuse, despite the facility's policy requiring immediate reporting of all alleged violations involving abuse, especially those resulting in serious bodily injury. This failure to report was confirmed through interviews with administrative staff, who acknowledged their decision not to notify authorities.