Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents. One resident, admitted with gastroenteritis, reported being hit on the shin with a cane by another resident, who had a history of congestive heart failure. The incident was reported by the affected resident to staff immediately after it occurred, and the resident was subsequently moved to a different room. However, a review of medical records showed no documentation that the alleged abuse was reported to the appropriate agencies within the required timeframe. Interviews with facility staff revealed that a licensed nurse was notified of the incident and promptly informed the Director of Staff Development (DSD). Despite this, the DSD did not report the alleged abuse to the relevant authorities, stating uncertainty about whether the abuse had actually occurred. The facility's policy required immediate reporting of all alleged abuse, but this protocol was not followed, resulting in a delay in notifying enforcement agencies.