Failure to Timely Report Alleged Abuse and Exploitation Between Residents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, as required by regulation. On the morning of 8/14/2025, a verbal altercation occurred between two residents in the dining room, during which one resident attempted to take another resident's personal coffee creamer, leading to a shouting match with cursing insults exchanged. The incident was witnessed by LVN A, who intervened and redirected the residents but did not report the allegation of verbal abuse and exploitation to the Administrator or follow the facility's established reporting procedures. A review of the residents' records revealed that both individuals involved had significant mental health and cognitive diagnoses. One resident had a history of mood disorder and schizoaffective disorder, with a care plan noting a potential for verbal aggression and a BIMS score indicating moderate cognitive impairment. The other resident had dementia, anxiety, and impulse disorders, with a care plan also noting a potential for verbal aggression and a BIMS score indicating cognitive intactness. Despite these risk factors and the escalation of the incident, the required immediate reporting to facility leadership and state authorities did not occur. Interviews confirmed that LVN A documented the incident in the nursing progress notes and reported it to the RN supervisor but did not escalate the report to the DON or Administrator as required. The DON later confirmed that she had not received any report of the incident and reiterated that staff had been trained to report all allegations of abuse, neglect, or exploitation. A review of the facility's policy confirmed the requirement for immediate reporting of such incidents to the Administrator and appropriate authorities, which was not followed in this case.