Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident physical and verbal abuse to the state survey agency, as required by policy. Two residents with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease were involved in an incident where one resident was witnessed by a CNA hitting and yelling at another resident. The incident was reported by the CNA to the facility administrator, but no investigation was initiated, and there was no documentation of the incident in either resident's medical record. Additionally, there was no abuse investigative file created for the altercation, nor was the incident reported to the state survey agency. Multiple staff interviews confirmed knowledge of the incident, with one CNA stating they witnessed the altercation and another staff member reporting that the affected resident was visibly upset and stated they had been hit. The facility's own Abuse Prevention and Reporting Policy requires prompt investigation and reporting of all abuse allegations to the state agency and documentation of all incidents, but these steps were not followed in this case.