Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State Survey Agency, ombudsman, and local law enforcement within the required two-hour timeframe, as mandated by facility policy. The incident occurred when one resident reported being kicked by another resident at the nursing station. The resident who experienced the incident immediately informed the Assistant Director of Nurses (ADON), who assessed both residents and separated them but did not escalate the report to the appropriate authorities. Interviews with facility staff, including the ADON, Medical Record Nurse, and social worker, revealed that although incident reports were filed internally, the event was not reported externally as required. Staff members indicated a lack of understanding or misinterpretation of the reporting requirements, with the ADON stating she did not consider the kick to be an allegation of physical abuse and the Medical Record Nurse expressing unawareness of the need to report to external agencies. A review of the facility's policy confirmed that all allegations of abuse must be reported immediately, defined as within two hours for abuse or serious bodily injury. The policy also specifies that such reports must be made to the administrator, state agency, ombudsman, law enforcement, and other relevant parties. Despite this, the required notifications were not made, and the incident was not thoroughly investigated in accordance with policy.