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F0609
D

Failure to Timely Report Alleged Resident-to-Resident Abuse

Bonham, Texas Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of resident-to-resident abuse was reported to the appropriate authorities within the required timeframe. Specifically, a CNA witnessed one resident strike another on the right arm and immediately reported the incident to an LVN. The LVN assessed the resident for injuries, found none, and reported the incident to the ADON and Administrator. Despite this, the incident was not reported to the state agency within two hours as required by regulation. The Administrator did not report the incident, stating that there was no injury and that the resident who was allegedly struck denied being hit. The Administrator also did not interview either resident involved in the incident. The ADON was under the impression that another resident had witnessed the event and did not speak to the involved residents or instruct the LVN to complete an incident report or skin assessment. The Executive Director stated that reporting was not necessary due to the cognitive status of the resident who allegedly struck the other. Record review showed that no incident or skin assessment was completed for either resident. The facility's own Abuse Prohibition Policy requires all allegations of abuse to be reported immediately or within two hours. The failure to report the witnessed incident of potential abuse in a timely manner constituted a deficiency in the facility's abuse reporting procedures.

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