Failure to Report Resident's Aggressive Incident Involving Staff Threats and Police Involvement
Penalty
Summary
Facility staff failed to report a behavioral incident involving a resident who was cognitively intact and had multiple medical diagnoses, including cerebral infarction, diabetes, and heart failure. The incident involved the resident becoming verbally aggressive and making threats toward multiple staff members after not receiving assistance following an episode of incontinence. The resident made statements threatening physical harm and referenced having family members come to the facility with weapons. Staff attempted to redirect the resident without success, and the situation escalated to the point where law enforcement was contacted. The administrator attempted to obtain an emergency custody order, but the magistrate determined the situation did not meet criteria for involuntary removal. The resident was later assessed by a psychiatry nurse practitioner, who found no credible threat for harm to self or others, and the police did not consider the threats credible. Despite the severity of the incident, which included police involvement, an attempted emergency custody order, and allegations from the resident regarding lack of assistance and violation of rights, there was no report made to the state agency or adult protective services (APS) as required by facility policy. The current administrator confirmed that the incident was not reported, stating the belief that reporting was unnecessary because the threats were directed at staff rather than other residents. Facility policy mandates immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment to the appropriate authorities, but this protocol was not followed in this case.