Failure to Identify and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving a resident who had recently been moved to a new room following an altercation with a roommate. The resident, who had diagnoses including COPD and generalized muscle weakness and was able to communicate needs, reported that their roommate had thrown items at them and that there had been several shouting matches. Despite these incidents, a review of the facility's incident logs showed no abuse allegation was logged for this resident. Progress notes documented verbal altercations and behavioral monitoring, but no formal incident report or state notification was made. Interviews with facility staff confirmed that an incident report should have been completed and the allegation reported to the state, but this did not occur. The facility's policy required immediate investigation and reporting of all alleged violations of abuse, including resident-to-resident altercations, within specified timeframes. The failure to follow these procedures resulted in the deficiency cited by surveyors.