Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, or misappropriation were reported immediately to the State Survey Agency, as required. Specifically, an incident occurred in which one resident grabbed another resident's walker and pushed it, causing the second resident to fall and sustain a large skin tear on his forearm. This event was documented in progress notes and reported internally to the Director of Nursing (DON) and Nurse Practitioner (NP), but was not reported to the State Survey Agency within the required timeframe. Resident records show that the injured resident had a history of thrombocytopenia, muscle weakness, recurrent falls, chronic kidney disease, and alcoholic cirrhosis, and required a walker for mobility. The resident's care plan included interventions to prevent falls, and wound care orders were in place following the incident. The resident who caused the fall had diagnoses including encephalopathy, cognitive communication deficit, Alzheimer's disease, and unspecified dementia, with documented behavioral issues and a care plan addressing potential for verbal and physical aggression. Interviews with staff revealed that the incident was reported internally but not externally, as the administrator did not believe the event constituted abuse due to a perceived lack of malicious intent. Facility policy required immediate reporting of all suspected or substantiated incidents of abuse, including resident-to-resident abuse, to the appropriate state agencies, but this protocol was not followed in this case.