F0609

D

Failure to Investigate Allegation of Resident-to-Resident Threat with Weapon

Norfolk, Virginia Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Facility staff failed to investigate an allegation of abuse involving one resident who had paraplegia and depression and was assessed as cognitively independent for daily decision-making. According to a nursing progress note, another resident reported that this resident had pulled a knife on him and that he feared for his life. The nurse notified the DON, who directed that the resident be placed on 1:1 supervision and remain in his room, and 911 was called. Police arrived and spoke with both residents but stated they did not have protocol to search the resident’s belongings. The nurse and a CNA attempted to search the resident’s belongings; the resident refused to allow a search of his bags but permitted a search of everything else and refused to stay in his room, leaving the unit.

Despite this allegation of a resident threatening another resident with a knife and the actions taken at the time, review of facility documents showed no evidence that an incident report or facility investigation was initiated or completed. During interview, the Administrator described the facility’s process for facility-related incidents, including that allegations of abuse, neglect, or mistreatment require initiation of an investigation within two hours, notification of external agencies, and completion of findings within five days. The Administrator acknowledged that no investigation could be located for this incident and that one should have been initiated. The facility’s written policy requires all allegations of abuse, neglect, exploitation, injuries of unknown source, and misappropriation of resident property to be reported immediately to the Administrator and appropriate agencies within prescribed timeframes, but this process was not followed for this event.