Failure to Timely Report and Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to immediately report and investigate an incident involving two residents, where one resident obtained a hand saw from an unlocked maintenance closet and used it to threaten another resident and damage her walker. The incident occurred when a male resident, with a history of Parkinson's disease, dementia, and behavioral issues, accessed the maintenance area and took a hand saw. He then threatened a female resident, who had Alzheimer's disease and moderate cognitive impairment, by stating he would cut off her foot and proceeded to saw a groove into her walker. Multiple staff members, including CNAs and nurses, became aware of the incident, and the saw was taken away from the resident at the time. Despite staff awareness, the incident was not reported to the facility administrator or to state authorities within the required federal timeframes. Interviews revealed that some staff reported the event to supervisors, but there was confusion and lack of clarity among the administrative team regarding the necessity and urgency of reporting the incident. The administrator and assistant director of nursing expressed uncertainty about whether the event constituted a reportable incident and did not initiate an investigation or ensure resident safety until prompted by surveyors during the inspection. Facility policy required immediate reporting of any allegations or suspicions of abuse, neglect, exploitation, or misappropriation of resident property to the administrator and appropriate authorities, with specific timeframes depending on the severity of the incident. However, the policy was not followed in this case, as the incident was not reported within the mandated two-hour or 24-hour windows, and no investigation was initiated until after surveyor intervention. This lapse was confirmed by staff interviews and review of facility records.