Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse involving two residents, as required by both facility policy and regulatory standards. Specifically, one resident with dementia and moderate cognitive impairment exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with no cognitive impairment. Despite these events, there was no evidence that the facility reported the allegations of abuse to the State Agency as required. Documentation in the medical records indicated that the resident with dementia made inappropriate sexual and combative comments to other residents and was involved in aggressive behavior on several dates. Staff documented these behaviors in progress notes but did not specify the exact nature of the comments or identify the recipients. Additionally, a verbal altercation between the two residents was documented, and staff intervened to separate them. However, there was no documentation of these incidents being reported to facility leadership or the State Agency, nor was there evidence of an investigation or follow-up as required by facility policy. Interviews with staff revealed uncertainty about whether the incidents were reported, and the Director of Nursing was unable to provide documentation of any investigation or reporting for the incidents in question. The Nursing Home Administrator, who was not employed at the time of the initial incidents, confirmed that the facility's policies require such events to be reported and that staff should notify leadership when incidents occur. The lack of timely reporting and investigation of these incidents constituted a deficiency in the facility's abuse reporting practices.