Failure to Investigate Resident's Verbal Threat in Accordance with Abuse Policy
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had previously exhibited behavioral issues including a prior altercation with a roommate, made a verbal threat in the dining room stating an intention to choke someone. This threat was overheard by a nursing assistant, who immediately reported the incident to the supervising nurse on two consecutive days. The supervising nurse did not respond to the report or assess the resident at that time. The nursing assistant subsequently reported the incident to another nurse, who then notified administration. Despite being notified, the administrator did not initiate an investigation, citing that the threat was not directed at a specific individual. No incident report was completed, and the facility failed to follow its abuse policy, which required immediate reporting, notification of administration, and initiation of an investigation for any suspected abuse or mistreatment. Interviews confirmed that the required steps, including documentation and investigation, were not taken in response to the verbal threat.