Failure to Timely Report Resident-on-Resident Abuse and Injury
Penalty
Summary
The facility failed to ensure timely reporting of an alleged incident of neglect involving two residents. One resident, who had a history of Alzheimer's Disease and dementia with moderate cognitive impairment, was found with a swollen and red face, as well as a skin tear to the right elbow. The resident was unable to describe what had happened due to cognitive limitations. Documentation and interviews revealed that the resident was assessed, treated for pain, and sent for further medical evaluation. The incident was determined to have involved physical aggression from another resident, who was also observed with a swollen and bruised hand. Despite the facility's policy requiring immediate reporting of abuse, neglect, or injuries of unknown source to the state survey agency and other authorities, the incident was not reported as required. The DON and Administrator acknowledged that the event was not self-reported to the Texas Health and Human Services Commission. The Administrator stated the decision not to report was based on the belief that the altercation lacked intent to harm, given both residents' low BIMS scores and their placement in the memory care unit.