Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident mental abuse to the State Agency as required by its own policy and federal regulations. The incident involved a resident with moderate vascular dementia and psychotic disturbance (the aggressor) verbally abusing their roommate, who had severe cognitive impairment. The aggressor used profane language, made derogatory remarks about the roommate, and demanded that the roommate and their family leave the shared room. The roommate's family member, visibly upset and concerned for the resident's safety, reported the incident to nursing staff and filed a grievance. Facility documentation shows that the incident occurred when the family member brought the resident back to their room and was met with verbal hostility from the roommate. The nurse on duty reported the incident to the DON, and the roommate was moved to another room. The family member completed a grievance form, which was submitted to the Social Service Director. However, the initial report to the State Agency was not completed until the following day, outside the required reporting timeframe for abuse allegations that do not result in serious bodily injury. The facility's policy mandates immediate reporting of abuse allegations, but staff did not recognize the incident as abuse at the time, partly because the family member did not explicitly use the term "abuse." The DON was notified, and the grievance was documented, but the delay in recognizing and reporting the incident resulted in a failure to meet the required reporting timeline. The administrator later acknowledged that the incident should have been reported on the day it occurred, regardless of the terminology used by the family member.