Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an alleged incident of resident-to-resident abuse involving one sampled resident. A resident reported that while in bed she heard a noise, got up, and found another resident in her bathroom. She stated that the other resident shoved the bathroom door open on her, screamed at her to get out of his room, shoved her against the wall, causing her to fall, then got on top of her, pulled her hair, and called her a “stupid b*tch.” She reported that she yelled for help and that an LPN and a CNA responded and separated the residents. The resident further stated she slapped the other resident after being called a derogatory name and informed the LPN of the shoving, hair pulling, and verbal insult. Review of the medical record showed no documentation of an incident or abuse allegation between the two residents. Interviews with administrative and nursing staff revealed that no incident report or abuse allegation had been reported to the administrator, DON, or ADON, and there were no SIMS reports related to this event. The LPN who responded acknowledged receiving abuse and incident reporting training but stated she did not report or complete an incident report because she did not believe the situation required reporting, citing that she did not personally witness physical contact and did not think the verbal comment constituted abuse. The RN weekend supervisor stated she was informed by the LPN that the resident had reported the other resident “put his hands on” her, but she also did not report the allegation because there were no injuries and she had not witnessed the incident. Both the LPN and RN confirmed they had received abuse training and understood that abuse allegations require reporting, and the DON confirmed that any allegation of abuse required reporting so that an investigation could be completed, which did not occur in this case.
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