Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. Specifically, the facility did not report a verbal altercation and threat involving two residents, despite facility policy and federal regulations requiring immediate reporting of such incidents. The incident involved one resident telling another that they would kill them, which was recognized by multiple staff members as verbal and emotional abuse and a reportable event. The events leading to the deficiency began when two residents, who were previously in a relationship, experienced a breakup that escalated into verbal altercations. One resident reported to staff that the other had threatened to kill them during an argument. This information was communicated to the Director of Nursing (DON), who did not immediately report the incident to the Administrator or DHSS, as required. The DON initially did not consider the threat serious due to the residents' ongoing arguments and relationship history, and only later reconsidered the severity of the incident. The Administrator was eventually informed but also failed to report the incident to DHSS, believing it was not a credible threat. Interviews with staff, including CNAs, a CMT, an LPN, and the Activity Director, revealed that they understood the requirement to report such allegations immediately and considered the threat to be abuse. Despite this, the DON and Administrator did not follow through with the mandated reporting process. The facility's own investigation confirmed that the incident was not reported to DHSS, and staff interviews corroborated that the reporting protocol was not followed as outlined in facility policy and regulatory requirements.