Failure to Prevent and Report Resident-to-Resident Abuse Involving Hazardous Item
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not implement its abuse policy when a male resident obtained a hand saw from an unlocked maintenance closet and used it to threaten a female resident and to saw a groove into the top, front bar of her walker. The incident was not promptly reported or investigated according to facility policy, and staff responses were inconsistent and delayed. The female resident involved had a history of Alzheimer's disease with late onset, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder. She had moderately impaired cognition and required assistance with activities of daily living. The male resident had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, and anxiety disorder, with moderately impaired cognition but was independent in ADLs. He admitted to obtaining the saw from the maintenance area and threatening the female resident, as well as using the saw on her walker. Multiple staff members were aware of the incident, with some witnessing the male resident in possession of the saw and using it on the female resident's walker. However, there was confusion and lack of clarity among staff and administration regarding the necessity and process for reporting the incident as abuse. The maintenance closet was found to be unlocked, allowing resident access to hazardous items. The incident was not reported to the DON or state authorities in a timely manner, and no immediate investigation or protective measures were initiated until prompted by surveyor inquiry.