Failure to Timely Report Resident-to-Resident Abuse Resulting in Psychosocial Harm
Penalty
Summary
The facility failed to immediately report a resident-to-resident physical altercation to the State agency as required. One resident, who had moderate cognitive impairment and a history of anxiety, delusional thinking, and psychiatric disorders, was repeatedly subjected to hair pulling and grabbing by another resident. Progress notes and staff interviews confirmed that these behaviors had been ongoing for several months, with staff attempts at redirection proving largely ineffective. The affected resident expressed fear and agitation as a result of these incidents, which ultimately contributed to her psychiatric hospitalization. Despite multiple documented incidents and staff awareness of the ongoing interactions, the facility did not report the altercation or the resident's reaction to the State agency within the mandated two-hour timeframe. Staff and management interviews revealed that the events were not recognized as reportable abuse, even though the facility's own policy defined abuse to include nonverbal contact causing fear or mental anguish. The care plan for the affected resident did not include specific interventions related to the other resident's behaviors, and staff had not been provided with new strategies to address the situation. The facility's Vulnerable Adult Abuse Prevention Policy required immediate reporting and investigation of all allegations of potential abuse, including those causing mental anguish. However, the ongoing pattern of physical and psychological distress experienced by the resident was not reported as required, and the facility did not initiate a formal investigation using its Behavioral Assessment Form. Staff interviews confirmed that management was aware of the situation, but no action was taken to escalate or report the incidents to the appropriate authorities.