Failure to Timely Report and Document Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its policy regarding the timely reporting and investigation of a resident-to-resident altercation, as well as the submission of a conclusion report within the required timeframe. Two residents were involved in altercations on two separate occasions, with staff witnessing and documenting the incidents in progress notes. Despite these documented events, the incidents were not reported to the State Agency as required by facility policy and regulatory standards. Resident 1, who had a history of bipolar disorder, schizophrenia, and peripheral vascular disease, was noted to have mildly impaired cognitive skills but was otherwise independent in activities of daily living and capable of making decisions. Resident 2, with diagnoses including hemiplegia, aphasia, and major depressive disorder, had severely impaired cognitive skills and required moderate assistance with daily activities. Both residents were involved in altercations, with staff noting physical and verbal aggression, and statements were obtained from witnesses. Interviews with facility staff, including the DON and Administrator, revealed that while the incidents were internally investigated and residents were separated, there was no documentation of the investigation or its outcome. Furthermore, the Administrator was not initially made aware of the incidents, and the required reports to the State Agency and other authorities were not submitted in accordance with the facility's abuse reporting policy. This failure resulted in a delay in external oversight and investigation of the alleged abuse.