Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse to the State Agency within the required two-hour timeframe for four residents reviewed for abuse reporting. Multiple incidents were observed and documented, including an event where one resident in the memory care unit was seen grabbing, pinching, and hitting another resident, causing the latter to scream. Staff intervened to separate the residents, but the aggressor was left unsupervised and subsequently attempted to lead another resident away. Review of incident and accident reports revealed several additional resident-to-resident altercations over a six-month period that were not reported to the State Agency as required. Interviews with facility leadership confirmed that none of the resident-to-resident altercations had been reported, as the Nursing Home Administrator believed such incidents were only reportable if they resulted in injury. The facility's own policy, however, mandates reporting all alleged violations involving abuse to the State Agency immediately, but not later than two hours after the allegation is made. The failure to report these incidents represents a deficiency in following both regulatory requirements and facility policy.