Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, as required by federal and state regulations. Specifically, an incident occurred in which one resident verbally threatened another resident, stating she would push her out of a window as she had done to a family member. This threat was overheard by staff, including Human Resources, who reported the incident to the facility Administrator, who also served as the abuse coordinator. Despite being informed of the threat, the Administrator did not document the incident or report it to the Health and Human Services Commission (HHSC), as required. The residents involved had significant medical and psychosocial histories. The resident who was threatened was severely cognitively impaired, dependent on staff for most activities of daily living, and had a history of anxiety and bipolar disorder. The resident making the threat was cognitively intact but had a history of bipolar disorder, depression, anxiety, and was known to refuse care. Staff interviews confirmed that the threatening resident had a pattern of verbally abusive behavior toward the other resident, and that this specific incident was reported to the Administrator immediately after it occurred. Despite the facility's written policy requiring immediate investigation and reporting of abuse allegations, the Administrator only contacted the Ombudsman and separated the residents, but did not fulfill the obligation to report the incident to HHSC. The Ombudsman also advised that the incident should be reported to HHSC. The lack of timely reporting and documentation of the abuse allegation constituted a failure to follow established procedures and regulatory requirements.