Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving a resident who was admitted for rehabilitation and was mildly cognitively impaired. Documentation in the electronic health record showed repeated incidents where another resident was observed yelling, cursing, and arguing with the resident, including threats to leave and ongoing loud verbal altercations. These incidents were documented by an LPN in the progress notes over several days, with descriptions of the disruptive behavior and the staff's attempts to manage the situation by assisting the resident and closing the door for privacy. Despite these documented incidents, the allegation of potential verbal and possibly physical abuse was not immediately reported to the Abuse Hotline as required by facility policy. Interviews with facility staff, including Social Services, the DON, and the Administrator, confirmed that the night shift nurse did not intervene or interview the residents at the time of the incident and only left a note for the DON. The delay in reporting and lack of immediate intervention were acknowledged by facility leadership as contrary to established procedures for handling abuse allegations.