Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency, as required by regulation. Multiple incidents involving both resident-to-resident and resident-to-staff allegations of abuse were not reported within the required timeframes. In several cases, incidents were reported days or even months after they occurred, despite staff being trained on the abuse and neglect policy and procedure. One incident involved a resident with severe dementia and agitation physically attacking another resident, resulting in scratches and hair pulling. Although staff intervened and separated the residents, the incident was not reported to the State Survey Agency until two days later. In another case, a resident pushed another resident, causing a fall, but the event was not reported for over two months. Staff interviews revealed confusion about reporting requirements, with some staff believing the incident was not reportable due to the cognitive status of the residents or lack of injury, despite facility policy mandating immediate reporting of all suspected abuse. Additional incidents included a resident accusing staff of abuse, which was not reported until two days after the allegation, and a physical altercation between two residents that was not reported to the administrator or State Survey Agency until three days after the event. Documentation and interviews confirmed that staff were aware of the incidents but failed to report them in a timely manner. The delays in reporting were attributed to miscommunication, assumptions about the severity or credibility of the allegations, and lack of clarity regarding who was responsible for making the report.