Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Department as required by policy and regulation. The incident involved a resident with Huntington's Disease, who had a history of behavioral outbursts, throwing a walker at another resident in the rehabilitation room, striking the second resident's left knee. Both residents were assessed as cognitively intact. The event was witnessed by the Director of Rehab (DOR) and a Physical Therapy Assistant (PTA), both of whom confirmed the altercation and acknowledged their status as mandated reporters. The DOR reported the incident to the facility's Administrator and DON, who indicated it would be handled, but the incident was not reported to the Department as required. Interviews with staff, including the DOR, PTA, and a licensed nurse, confirmed that the event was recognized as a resident-to-resident altercation and should have been reported. However, the DON stated the facility did not consider the incident as abuse, but rather as a behavioral outburst, and therefore did not report it to the Department. Review of the facility's policy indicated that all alleged violations involving abuse must be reported immediately or within specified timeframes, but this procedure was not followed in this case.