Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for two residents who were involved in a verbally aggressive incident. Both residents had intact cognition and were diagnosed with mental health conditions such as bipolar disorder, depression, and schizophrenia. The incident occurred on the facility's patio, where one resident made inappropriate and aggressive comments towards the other, resulting in a verbal altercation that included cursing and shouting. Staff members, including a Licensed Vocational Nurse and a Social Service Assistant, witnessed or were made aware of the incident and acknowledged that all abuse allegations, including verbal aggression, should be reported immediately to supervisors and the administrator. Despite the facility's policy requiring immediate reporting of all abuse allegations, including verbal abuse, to the administrator and appropriate authorities, the incident was not reported to the state agency. The Director of Nurses confirmed that the incident was not reported, and the administrator stated that the event was not investigated as abuse because it was perceived as only verbal aggression. Multiple staff interviews indicated awareness of the incident, but no formal report or investigation was initiated as required by facility policy and state regulations. The failure to report the incident resulted in a delay in an onsite inspection by the state agency and had the potential to place other residents at risk for unaddressed abuse and unsafe interactions. The facility's own policy defined abuse to include verbal aggression and mandated reporting to law enforcement and the state agency within two hours of an initial report, which was not followed in this case.