Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident physical abuse to both the administrator and the state survey agency for two residents. One resident, who is cognitively intact and requires substantial assistance for transfers, reported that another resident with severe cognitive impairment and a history of aggressive behaviors struck her in the back of the neck while in the dining room. This incident caused the resident neck pain for several days and triggered emotional distress due to past trauma. The incident was witnessed by a CNA, who reported it to an LPN, but not directly to the administrator as required by facility policy. Multiple staff members, including the CNA, LPN, Activity Director, and Maintenance Director, were aware of the altercation or its aftermath, and it was discussed in a morning meeting that the two residents should be kept apart. However, there was no documentation of the incident in either resident's medical records, no abuse investigative file was created, and the incident was not reported to the state survey agency. The administrator, upon being informed, determined the event was accidental and did not consider it abuse, thus did not initiate the required reporting process. The facility's policy requires all possible incidents of abuse to be identified, investigated, and reported within federally mandated time frames. Despite this, the incident involving physical contact and resulting distress was not properly documented, investigated, or reported as an abuse allegation, representing a failure to follow established protocols for abuse prevention and reporting.