Failure to Timely Report and Investigate Resident Threat
Penalty
Summary
The facility failed to act promptly on a report of a verbal threat made by a resident with a history of behavioral issues, including a prior altercation with a roommate. The resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy and a history of alcohol dependence, made a threatening statement in the dining room that was overheard by a nursing assistant. The nursing assistant reported the incident immediately to a nursing supervisor, who did not respond or investigate the situation. The assistant reported the incident again the following day to the same supervisor, who again did not act. The incident was finally reported to another supervisor two days later, who then initiated a psychiatric consult and placed the resident under observation. Despite the eventual response, the facility did not complete an incident report or initiate an investigation at the time the threat was first reported. The State Agency was not notified of the verbal threat, contrary to facility policy, which requires immediate reporting and investigation of suspected abuse or threats. Interviews with staff and the administrator confirmed that the incident was not acted upon in a timely manner, and documentation failed to show that required notifications and investigations were completed as per policy.