Failure to Report Resident-to-Resident Abuse Allegations to Ombudsman and APS
Penalty
Summary
Facility staff failed to implement the abuse reporting policy for a resident involved in multiple resident-to-resident altercations. Clinical record review showed a progress note dated 11/2/25 documenting that the resident was witnessed telling another resident to move from in front of his door while holding a butter knife and yelling, "move her from in front of my door." Staff removed the resident and attempted to take the butter knife, but the resident refused to relinquish it. A separate facility investigation summary dated 9/12/25 described an incident in which the same resident was struck from behind by another resident and responded by striking the other resident back. During an interview, the resident was unable to provide details about these incidents and reported that he gets along with everyone. Review of facility documentation on 1/7/26 revealed that the facility failed to send the investigation summary related to these incidents to the Ombudsman and Adult Protective Services as required by its abuse policy. The policy titled "Reporting Requirements/Investigations" required the Administrator to immediately report any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to the State Agency within specified time frames, and to notify Adult Protective Services, the local Ombudsman, and appropriate law enforcement for any incident of patient abuse, mistreatment, neglect, misappropriation of personal property, or other reasonable suspicion of a crime. Surveyors found no credible evidence that the incidents involving this resident were reported to the Ombudsman in accordance with this policy.
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