Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving one resident to the State Survey Agency as required by federal regulations. The incident involved a resident who reported being threatened by another resident. The resident's family member also contacted the facility, expressing concern and threatening to call emergency services if the situation was not addressed. The facility responded by moving the resident to another room for comfort and safety, and the incident was communicated to the management team and the Director of Nursing (DON). Despite the internal response, the incident was not reported to the State Survey Agency. During interviews, the Administrator acknowledged that the incident should have been reported, and the DON confirmed that the event was not escalated beyond internal management. The facility's own policy and the signed employee attestation required prompt reporting of any reasonable suspicion of abuse to the appropriate authorities, but this protocol was not followed in this case. Both residents involved were cognitively intact at the time of the incident, as indicated by their BIMS scores. The failure to report the allegation of abuse, as required by both federal regulation and facility policy, was confirmed through record review and staff interviews. The deficiency was identified during a review of documentation and interviews with facility leadership, who admitted the reporting process was not completed as required.
Plan Of Correction
How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Training: The facility's Abuse Prevention and Reporting Policy was reviewed with a focus on the reporting timeline (within 2 hours for abuse involving serious bodily injury, and within 24 hours for all other allegations). Staff Re-Education: All staff—including licensed nurses, CNAs, and department heads—were in-serviced on mandatory reporting obligations per F609 and the internal reporting protocol. Chain of Reporting Tools: Abuse reporting binders were reviewed for accuracy. How does the facility plan to monitor its performance to make sure solutions are sustained? The Administrator or designee will audit all incident reports and grievances weekly for 12 weeks to ensure any allegation of abuse, neglect, or mistreatment is properly reported within regulatory timelines. Results of audits will be reviewed quarterly during the QAPI meeting and corrective actions taken if patterns are noted. Completion Date: May 8, 2025 F 609 F 609