Failure to Investigate and Report Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to document, report, and conduct a thorough investigation of an allegation of resident-to-resident verbal abuse. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene, reported that after her admission she used her roommate’s landline phone while the roommate (Resident B) was out of the facility. When Resident B returned, she became upset that Resident C was using her phone and threatened Resident C, stating that if anyone touched her belongings she would kill them. Resident C and her sister, who was on the phone at the time, both reported that Resident B threatened to kill Resident C and Resident C’s sister if they continued to use or call the phone. Resident C stated she informed a CNA about the threats and was moved to another room that evening, but she did not report the threats directly to a nurse. She later reported that Resident B continued to intimidate her by walking past her new room and making a finger gun gesture toward her. Resident C discussed these concerns with the Social Services Director (SSD) and expressed that she did not feel safe with Resident B in the facility, and she had considered finding another facility. An Adult Protective Services (APS) online report identified Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and including threats of physical harm made on the night Resident B returned from a psychiatric hospital stay. The SSD reported that she was notified after hours by a CNA that Resident B was threatening Resident C and being verbally aggressive, and she instructed staff to move Resident C and to contact the police. However, she did not recall who called her, was unsure if the DON was informed, and did not interview staff about the reported ongoing finger gun gestures. The DON indicated she was only aware of an altercation between Resident B and Resident C’s sister over the phone and believed there had been no resident abuse, so no investigation was initiated. The DON was unaware of the reported death threats, the APS report, or any police contact, and later learned from law enforcement that no police report had been filed. As a result, the facility did not complete required documentation, did not report the alleged threats to the state agency within the required timeframe, and did not conduct a thorough investigation into the allegation of resident-to-resident verbal abuse.
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