Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure for two residents when it did not investigate an allegation of abuse. On 12/18/2025, one resident reported to a registered nurse that she was being harassed and assaulted by another resident. The reporting resident described an incident where the other resident went through her clothes, punched her in the chest, called her derogatory names, and made offensive remarks. The resident stated she reported this incident to the nurse, but there was no evidence that the allegation was reported to the abuse coordinator or that an investigation was initiated as required by facility policy. Both residents involved had moderately impaired cognitive skills for daily decision making and required varying levels of assistance with activities of daily living. The resident who reported the abuse had diagnoses including type 2 diabetes mellitus, hypertension, and schizoaffective disorder, while the other resident had diagnoses including malignant neoplasm of the vulva, chronic diastolic heart failure, and cardiomegaly. Despite the report of abuse, the staff member who received the allegation did not follow the facility's policy to report and investigate the incident, and key personnel such as the Social Services Director and Director of Nursing were not informed in a timely manner. Interviews with staff confirmed that the facility's abuse prevention and reporting policy was not followed. The Social Services Director and Director of Nursing both stated they were unaware of the abuse allegation until after the fact, and the registered nurse admitted she did not report the incident as required. The facility's policy mandates prompt investigation and reporting of abuse allegations to appropriate authorities, but this process was not initiated, and documentation was lacking.