Failure to Report and Investigate Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy by not reporting and fully investigating an allegation of resident-to-resident verbal/mental abuse. One resident (R7), who has multiple medical conditions including blindness in the left eye, hypertension, diabetes with proliferative diabetic retinopathy, hyperlipidemia, and a history of falls, reported that another resident (R16) was harassing and threatening her. A progress note dated 2/16/2026 by an LPN (V47) documented that R7 complained of being harassed by another patient, requested to be taken to her room, and stated she heard that other patients might attack her if she was seen in the dayroom the next day. The note further documented that R16 came to R7’s room, continued to bother and harass her despite being asked to leave, and that R7 was crying and called her family, who came to the facility, creating an intense situation. On subsequent interviews, R7 stated that R16 repeatedly came to her room, harassed her, told her he would get people to beat her up, and interfered with her wig. R16 acknowledged an altercation with R7 but denied threatening her, stating he told her to stop messing with people and that if she put her hands on him, he would do the same. A family member (V48) reported that R7 called her crying about R16, and that when the family came to the facility, they were told that R16 had gone to R7’s room, pushed her door open, and told R7 she better not come to the dining room or he would “f her up.” A CNA (V45) confirmed receiving a phone call from an upset family member stating that R16 had said something to R7, and an RN (V18) reported being called to the floor because R7’s family was present after R7 reported that R16 had threatened her. Despite these reports and the facility’s written abuse policy defining mental and verbal abuse to include harassment and threats, and specifying that resident-to-resident altercations should be reviewed as potential abuse and reported to the Department of Public Health within required time frames, the administrator (V1), who is the abuse coordinator, stated that he did not have any investigation or reportable for the incidents involving R7 and R16 because he did not consider it abuse. When asked if he conducted any investigation to determine whether abuse occurred, he stated that staff statements were his investigation and confirmed that no formal investigation or reportable was completed. This failure to treat the resident’s allegations and the documented threats as a reportable abuse allegation and to conduct a thorough investigation constitutes the cited deficiency.
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