Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to follow its policy and federal regulations regarding the reporting and investigation of alleged abuse when an incident occurred involving two residents. One resident alleged that another resident hit him on the right cheek, and in response, he hit back. The incident was witnessed by staff, and the involved residents were both found to be cognitively intact and able to make decisions. Documentation in the medical record described the event as an accidental graze to the cheek, with no injury noted, and the responsible party and physician were notified. However, staff interviews revealed that the incident was described as an altercation and considered by the charge nurse to be abuse, which should have triggered immediate reporting and a thorough investigation as per facility policy and federal requirements. Despite these requirements, the facility did not report the alleged abuse to the appropriate authorities, including the State Survey Agency and law enforcement, nor did it conduct a thorough investigation as required. The Director of Nursing confirmed that the incident should have been reported and investigated according to policy. This failure to report and investigate the alleged resident-to-resident physical altercation had the potential to leave the involved residents and others at risk of unaddressed abuse.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/12/25, after Administrator and DON were notified of the alleged abuse incident, immediate review of the incident was conducted. Upon review of 5/28/25 incident residents 1 and 2 were separated, monitored, and provided protective measures. Both resident 1 and 2 were assessed by the charge nurse, with no injuries identified. The physician, and responsible parties were notified of the incident. Resident 1 remains in the facility without any physical or psychological distress. On 6/12/25, the Administrator, DON, RN Supervisor, and charge nurse completed rounds and reviewed facility charts and current residents to determine if any other residents had been affected by the same deficient practice. No other residents were identified to have been affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A comprehensive audit of current residents' records was conducted by the Medical Records Director (MRD), DON, and Administrator on 6/12/25 to assess for any unreported or delayed reports of alleged abuse. No additional incidents of unreported allegations were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, the DON initiated facility-wide in-service training for staff on the facility's Abuse Prevention Policy and Reporting Procedures, in accordance with federal and state regulations. The training emphasized the following: - All allegations or suspicions of abuse must be reported immediately to the Administrator (Abuse Coordinator), DON, and appropriate state agencies. - Immediate protection of the resident involved is mandatory while the investigation is ongoing. - Documentation of the incident, notification of responsible parties, and reporting to regulatory agencies must be completed promptly. - Staff understanding of the difference between suspicion of abuse and confirmed abuse, reinforcing the obligation to report suspected abuse without delay. - The Abuse Policy has been updated to include a mandatory reporting checklist to assist staff in ensuring compliance. - The Abuse Coordinator (Administrator) will review all incident reports weekly for compliance with reporting protocols. How the facility will monitor its performance to ensure solutions are sustained: The Medical Records Director will conduct weekly audits of incident reports for 3 months starting the month of June to September 2025 to verify timely reporting and documentation of suspected abuse. Results of the audits and any identified deficiencies will be presented to the monthly QA Committee for review and further action. Quarterly QA meetings will continue to review trends, audit findings, and provide recommendations for ongoing compliance for a minimum of two quarters or until compliance is fully sustained. The Administrator (Abuse Coordinator) and DON will provide ongoing oversight to ensure that all reporting requirements remain in full compliance with regulations.