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F0609
D

Failure to Report Resident-to-Resident Physical Abuse

Coldwater, Ohio Survey Completed on 04-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an incident of resident-to-resident physical abuse to the state agency as required by both facility policy and state regulations. The incident involved a resident with Alzheimer's disease and psychotic disorder who was struck and pushed by another resident with dementia and severe cognitive impairment in a common area. The altercation was witnessed by staff, and although the resident who was struck did not fall, a bruise was later observed on her upper arm. The event was documented in the medical records and confirmed by staff interviews, including a CNA and an RN who attributed the bruise to the altercation. Despite the facility's policy requiring notification of all alleged abuse to the Ohio Department of Health within 24 hours, the incident was not reported. Interviews with the Administrator and the Regional Director of Clinical Services confirmed that the event met the definition of physical abuse and should have been reported. Review of the state agency's reporting system showed no record of the incident being reported, confirming the facility's non-compliance with mandatory reporting requirements.

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