Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure timely notification to the State Agency regarding an allegation of verbal abuse between two residents. On the date of the incident, one resident with a history of bipolar disorder and moderate cognitive impairment engaged in a verbal confrontation with another resident who was alert and oriented. The confrontation included threats of physical violence, with one resident referencing a prior incident where physical aggression had occurred. Staff, including a social worker, observed and documented the altercation, and the involved residents were separated. The resident who initiated the threats was later calmed and escorted back to their room by the ADNS. Despite multiple staff members documenting the incident in the medical record, there was a breakdown in communication regarding the reporting of the event. The social worker, psychiatric APRN, and nursing staff all made notes about the incident, but the DON was not informed about the resident-to-resident verbal aggression and threats. The DON stated that if she had been notified, she would have recognized the event as an allegation of verbal abuse and reported it to the State Agency as required by facility policy. The facility's abuse policy mandates that allegations of abuse be reported promptly, with supervisors immediately notifying the DON and Administrator, who are responsible for reporting to the State Agency within two hours. However, the State Agency was not notified until 51 days after the incident, following inquiry by surveyors. This delay constituted a failure to follow established procedures for timely reporting of suspected abuse.