Failure to Timely Report and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Investigation and Reporting policy for one resident who alleged physical abuse by another resident. Specifically, after a resident reported to an RN that another resident had jumped on and hit his head, the incident was not reported to the State Agency, ombudsman, or local law enforcement within the required two-hour timeframe. The Director of Nursing confirmed that the allegation should have been reported and investigated promptly, but this did not occur, and the DON was not made aware of the incident until several hours later. Additionally, the facility did not immediately separate the two residents involved in the alleged abuse, as required by policy to prevent further harm. Both residents remained in the same room for nearly six hours after the incident was reported, despite one resident expressing discomfort about sharing a room with the alleged abuser. The facility's own policies indicated that residents should be protected from abuse and separated during investigations, but these procedures were not followed in this case.