Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the mandated timeframe for one resident. According to the facility's policy, allegations of abuse, including physical altercations between residents, must be reported to the administrator immediately and to the state agency within two hours if there is alleged abuse or serious bodily injury. In this incident, a resident with schizophrenia and a history of traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, and the incident was documented in the facility's FRI. However, the FRI was not submitted to the State Agency within the required timeframe. The LPN involved was new and unfamiliar with the FRI process, so she sought assistance from the DNS and another nurse, which contributed to the delay. The DNS confirmed that she was in contact with the LPN multiple times regarding the incident, but acknowledged that the report was not completed and submitted as mandated.