Failure to Report Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving two residents to the Office of Long-Term Care, as required by regulation and facility policy. One resident, with a history of intellectual disabilities and traumatic brain injury but intact mental cognition, was struck and bruised by another resident who had moderate vascular dementia and a history of physical aggression. The incident was witnessed by a CNA, who immediately informed administration, and the injured resident reported pain, fear, and a visible bruise to staff and the Social Director. The incident was documented in an internal incident report, and both the DON and Administrator were notified on the day of the event. Despite these notifications and the presence of a bruise, the DON stated that no reportable event was filed with the Office of Long-Term Care because there were "no injuries." The Medical Director was not notified of the incident, and staff interviews confirmed the altercation and resulting injury. Facility policy and recent staff training required immediate reporting of all allegations of abuse to appropriate authorities, but this was not followed in this case.