Failure to Report and Investigate Resident-to-Resident Verbal Abuse and Death Threats
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff reported and investigated an allegation of resident-to-resident verbal abuse, including death threats, in accordance with abuse reporting requirements. A cognitively intact resident, identified as Resident C, was newly admitted and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene. After her cell phone and charger stopped working, staff arranged for her to use her roommate’s landline phone while the roommate, Resident B, was out of the room at a psychiatric facility. When Resident B later returned, she became upset that Resident C was using her landline phone and, according to Resident C and her sister, threatened to kill Resident C and her sister if they touched or used her belongings or called the phone again. Resident C reported that Resident B told her, “If anyone touches my stuff, I’m going to kill you,” and made similar threats toward her sister over the phone. Resident C stated she informed a CNA about the threats, and the CNA confirmed that Resident C said Resident B “keeps threatening me” and that Resident C’s sister reported ongoing threats over the phone. The CNA reported the allegation to the Unit Manager. Resident C was moved to another room the same evening, but she later reported that she did not feel safe and that Resident B continued to walk by her new room and make a finger-gun gesture toward her. Resident C’s sister corroborated hearing Resident B threaten to kill both Resident C and herself during the phone call. The Social Services Director (SSD) stated she was called at home after hours by a CNA and informed that Resident B was threatening Resident C and being verbally aggressive. She instructed staff to move Resident C and to contact the police, and she submitted an Adult Protective Services (APS) report listing Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and threats to physically harm Resident C. However, the DON reported that she was only told there had been an altercation between Resident B and Resident C’s sister over the phone and believed the issue did not involve resident abuse. The DON stated there was no investigation because she understood the incident to be between Resident B and the sister, not involving Resident C as a victim, and she was unaware of any threats, APS report, or police involvement. She did not conduct staff or resident interviews related to the threats, and there was no report made to the state agency within the required timeframe for alleged abuse. The facility’s abuse-reporting policy required associates who suspect a crime against a resident to immediately notify the Executive Director, but the DON remained uninformed of the full nature of the threats and no formal abuse investigation was initiated.
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