Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to the State Agency and Adult Protective Services within the required two-hour timeframe. One resident, who had diagnoses including anoxic brain damage and paraplegia but was cognitively intact, reported to his insurance case manager that he was struck in the face and choked by another resident. The incident was said to have occurred in a hallway while staff were present, and a Life Enrichment Associate confirmed witnessing the event. However, the facility's self-report investigation did not include an interview or statement from this staff member, and staff working at the time denied witnessing the altercation. The Executive Director, who serves as the facility's abuse officer, confirmed that staff are trained to report suspected abuse immediately to management, who are then responsible for notifying the appropriate agencies within two hours. Despite this policy, the Executive Director only became aware of the incident through the resident's insurance case manager and was unable to confirm the date of the incident or identify witnesses during the investigation. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, but this process was not followed in this case.