Failure to Immediately Report Suspected Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to immediately report an incident involving two residents, one of whom had dementia, osteoporosis, muscle weakness, and required extensive assistance with activities of daily living. The incident occurred when one resident made contact with another's shoulder in an attempt to maneuver around her prior to a supervised smoke break. The certified medication aide (CMA) who witnessed the event did not report it to the charge nurse until nearly two hours later, despite facility policy requiring immediate reporting of suspected abuse or mistreatment. The resident who was contacted had a care plan indicating the need for close supervision due to cognitive impairment, physical limitations, and behavioral issues related to dementia and anxiety. The care plan also specified interventions for supervised smoking and behavioral management to protect the safety of all residents. At the time of the incident, the resident was receiving hospice services and was on multiple medications, including antidepressants, antipsychotics, and opioids. Facility policy clearly outlined the responsibility of all staff to promptly report any suspected abuse, neglect, or mistreatment to facility management, with immediate examination and documentation required. In this case, the delay in reporting by the CMA resulted in a failure to follow established procedures, placing the resident at risk for ongoing mistreatment and inadequate supervision.