Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
Facility staff failed to report an allegation of resident-to-resident physical abuse to the State Agency within the required two-hour timeframe for two residents. One resident, with a history of schizoaffective disorder, paranoid schizophrenia, and psychosis, reported that her previous roommate threw a chair at her. The incident was not reported to the State Agency until the surveyor brought it to the attention of the facility's social worker and program director. The facility's policy and process require that such allegations be reported within two hours, but the mandated reporting form (SOC-341) was not sent until several hours after the allegation was made known to staff. The records reviewed indicated that both residents involved had significant mental health diagnoses but were assessed as not having cognitive impairments. The incident was only discovered after a resident disclosed the altercation during an interview with the surveyor, and the facility's documentation showed the resident had been moved to another room due to incompatibility, without any prior report of abuse. The delay in reporting was confirmed by interviews with facility staff, including the program director and administrator, who acknowledged the requirement for timely reporting and the failure to meet it in this case.