Failure to Identify, Report, and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify, report, and investigate two separate allegations of abuse made by a cognitively intact resident against another resident. On two occasions, the resident reported feeling threatened, scared, and unsafe after being verbally threatened and intimidated by another resident, who was known to have a diagnosis of schizophrenia and a history of verbal aggression. The first incident involved the alleged aggressor raising a clenched fist and threatening to kill the reporting resident over a dispute about a wheelchair. The second incident involved the alleged aggressor threatening to cut the reporting resident into pieces. Both incidents were reported by the resident to facility staff, including an LVN and the DON. Despite these reports, the facility's Administrator, who also served as the Abuse Coordinator, was unaware of the allegations and did not initiate the required reporting to the state agency or conduct an investigation as outlined in the facility's abuse policy. The policy required immediate investigation and reporting of all alleged violations to the Administrator and state agency, with thorough documentation and follow-up. Interviews confirmed that the LVN and DON were informed of the incidents, but the Administrator did not receive this information and therefore did not fulfill the mandated procedures for abuse allegations. Additionally, another resident corroborated the occurrence of verbal threats by the alleged aggressor, stating that such behavior was frequent. The medical records indicated that the alleged aggressor lacked capacity to understand and make decisions, while the reporting resident was cognitively intact and able to articulate her concerns. The failure to follow established protocols for abuse allegations resulted in the incidents not being properly addressed or investigated by facility leadership.