Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving abuse between two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, and behavioral problems including physical aggression and peer altercations, became physically aggressive during a medication pass. The resident yelled at a nurse, pointed a finger close to the nurse's face, and then charged at another resident, grabbing his arm and attempting to drag him to the floor. Staff had difficulty separating the two residents, and the aggressive resident attempted to throw a chair before being stopped by staff. The incident resulted in the second resident sustaining slight discoloration to his left arm and a ripped shirt sleeve. Despite the severity of the altercation, the facility did not initiate an investigation or notify all required parties until the following day, outside of the facility's policy requirement to report suspected abuse immediately, defined as within two hours. Clinical records and interviews confirmed the delay in reporting. The facility was unable to provide investigation documents beyond 12 months, and policy review confirmed the expectation for immediate reporting and investigation of abuse allegations.