Failure to Timely Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of suspected resident-to-resident abuse involving a resident who sustained significant injuries, including a non-displaced acute distal right clavicle fracture, diffuse osteopenia, and a subdural hematoma with mild midline shift, after being found on the floor in her room. The incident was initially documented as an unwitnessed fall, but multiple staff interviews and confidential concerns indicated that another resident, known for aggressive behaviors and prior resident-to-resident altercations, was seen exiting the injured resident's room immediately after the event, with fresh scratches on her arm. The injured resident, while at the hospital, repeatedly stated that a nurse had twisted her arm behind her back, causing her to fall, and also pointed to the other resident as being involved when questioned by staff. Despite these statements and observations, the facility did not immediately report the incident as suspected abuse. The facility's internal teams, including the Interdisciplinary team, Quality Assurance, and QAPI, reviewed the event and decided not to report it as resident-to-resident abuse, concluding it was a fall with injury. The incident was only reported to the state as a fall with injury after the hospital report confirmed the extent of the injuries. The facility did not attempt to contact the EMTs, hospital staff, or the family member after the resident was discharged to the hospital, and relied on a conversation with the family member, who appeared to agree it was an accident, as justification for not reporting suspected abuse. The resident who was suspected of causing the injury had a documented history of aggression, wandering, and prior altercations, both at the current facility and at a previous facility. Staff were instructed to keep the resident on 15-minute checks and to monitor her closely, but at the time of the incident, staff were occupied with other duties and did not have eyes on her. The facility's policy required all alleged violations involving abuse to be reported immediately, but no later than 2 hours after the allegation was made. However, the facility did not report the incident as abuse within this timeframe, despite multiple indicators and concerns raised by staff, family, and external parties.