Failure to Report Resident-to-Resident Abuse Incidents to Required Agencies
Penalty
Summary
Facility staff failed to timely report incidents and allegations of abuse involving one resident to all required agencies and within required timeframes. Clinical record review of this resident’s chart 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, yelling for the other resident to be moved. Staff removed the other resident and attempted to take the butter knife, but the resident refused to give it up. This incident, which constituted an allegation of abuse, was not documented as having been reported to all required external agencies as specified by facility policy. Further review of facility documentation revealed an investigation summary dated 9/12/25 describing an incident in which the same resident was struck from behind by another resident and responded by striking the other resident back. The facility had no credible evidence that this incident was initially reported to the state survey agency or Adult Protective Services when it occurred. Additional review on 1/7/26 showed the facility lacked credible evidence that the investigation summary related to the butter knife incident had been sent to Adult Protective Services. During an interview, the resident was unable to provide details about the incidents and reported getting along with everyone. The facility’s written policy required immediate reporting of alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to the state agency within specified timeframes, and notification of Adult Protective Services, the local Ombudsman, and appropriate law enforcement for any incident of patient abuse, mistreatment, neglect, misappropriation, or reasonable suspicion of a crime, but these requirements were not met for the incidents involving this resident.
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