Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow and implement its abuse policy for one of three sampled residents after an allegation of abuse was made. On 3/15/25, a resident reported that another resident hit her on the left shoulder, resulting in pain and limited movement of her left arm. The incident was witnessed by an occupational therapist, who intervened and informed the second resident to use the resident's name instead of tapping her. The registered nurse supervisor was notified and assessed the resident, finding no bruising or discoloration, but the resident continued to complain of pain. The nurse practitioner was notified, and orders for pain management and an x-ray were given, with the x-ray result being negative. Despite the resident's allegation of being hit and subsequent pain, the facility did not report the allegation of abuse to the state survey agency within two hours as required by their policy. Interviews with staff, including the assistant director of staff development, confirmed that the facility's policy mandates reporting any abuse allegations to the administrator and the state agency within two hours of awareness. However, the director of nursing and administrator stated they did not report the incident because the occupational therapist witnessed the event and determined that no abuse occurred. The facility's policy on abuse and mistreatment requires reporting all alleged and substantiated violations to the state agency and taking necessary corrective actions based on the investigation results. In this case, the failure to report the allegation in a timely manner constituted a deficiency in following established abuse reporting protocols, regardless of the staff's assessment of the situation.