Failure to Timely Report Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving Resident 15, as required by its abuse reporting policy. Resident 15 had diagnoses including anxiety disorder, metabolic encephalopathy, and dementia, and was documented as lacking capacity to understand and make decisions, with moderately impaired cognitive skills and a need for partial to moderate assistance with ADLs. On a Change of Condition form dated 1/22/2026, Resident 15 stated during a nursing interview that their roommate had grabbed their neck the previous week. Resident 17, who was the roommate, also had anxiety disorder and metabolic encephalopathy, lacked capacity to understand and make decisions, and had moderately impaired cognitive skills with a need for partial to moderate assistance with ADLs. On 1/15/2026, Resident 17 was noted to have increased confusion and verbal aggression with staff, was kept at the nurses’ station for close supervision, and was prescribed PRN lorazepam for verbal aggression. Social service notes indicated that Resident 17 was moved to a different room and later discharged to a general acute hospital for behavioral evaluation. On or about 1/15/2026, RN 1 was informed by an LVN and a CNA that Resident 17 had touched Resident 15 on the neck; RN 1 assessed Resident 15 and found no redness or changes and informed the DON, who started an investigation. On 1/16/2026, Family Member 1 reported to RN 3 by phone that Resident 15 said Resident 17 had choked them; RN 3 then interviewed Resident 15, who repeated the allegation that the roommate choked them on the neck. Resident 15 also told LVN 6 that they had been choked by Resident 17. RN 3 acknowledged not reporting this allegation to the administrator, the Department, the Ombudsman, or local law enforcement, and LVN 6 acknowledged not reporting the allegation to the administrator. Family Member 1 reported the choking allegation to the DON, and the DON later stated they did not report the allegation to the Department, the Ombudsman, or law enforcement. The administrator stated they did not receive an allegation of abuse report from staff on 1/16/2026. The facility’s policy required that suspicion of abuse be reported immediately to the administrator and to the Department, Ombudsman, and local law enforcement within two hours of an allegation, which did not occur in this case.
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