Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required 24-hour timeframe to Adult Protective Services (APS) for one resident. According to the facility's policy, all staff, residents, and visitors are required to immediately report any incidents or suspected incidents of abuse, neglect, or exploitation. The policy further specifies that staff must notify the charge nurse, department head, or administration immediately, and that the administrator or designee must notify APS within 24 hours if the incident does not result in bodily harm. In this case, an incident involving resident-to-resident abuse occurred, but administration was not notified until several days later, and APS was not contacted until after the 24-hour window had passed. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 6, and was dependent on staff for all activities of daily living. The incident was first identified in a facility investigation initiated by the administrator, which revealed that the event had occurred days prior and that no injury had resulted. The Director of Nursing confirmed that staff did not immediately notify administration as required, despite previous education on the reporting process. As a result, the allegation of abuse was not reported to APS within the mandated timeframe.