Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for one of the residents. According to the facility's policy, all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and the applicable State Agency. However, an incident involving resident-to-resident abuse occurred on 12/31/24, where one resident was hit by another resident. Despite the incident being documented in a progress note, it was not reported to the State Agency until 1/16/25, which is beyond the required reporting timeframe. The resident involved in the incident, identified as Resident R80, was admitted to the facility with diagnoses of anemia, dementia, and depression. The progress note indicated that Resident R80 was hit in the face and on the left side with a cane by another resident, Resident R66, while walking in the hallway. Although there were no obvious signs of trauma, the resident expressed fear of the incident recurring. The failure to report this incident in a timely manner was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the Director of Nursing did not report the abuse allegation as required.
Plan Of Correction
The facility cannot retroactively go back and make corrections. Moving forward, the facility will report allegations of resident to resident abuse in the required timeframe. To identify other residents that have the potential to be affected, the DON/designee completed an audit of current resident events from date of exit (1/16/2025 to current) to ensure timely reporting if needed. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to the NHA and DON on the regulatory requirements of F609 and timely reporting of resident to resident abuse. To monitor and maintain ongoing compliance, the NHA/designee will audit resident events weekly x4 then monthly x 2 to ensure those occurrences that meet the requirement are reported timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. Facility submitted event to ERS-event #1070939.