Failure to Timely Report Resident-to-Resident Altercation and Abuse Allegation
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident-to-resident altercation to the State agency within the required timeframe. The incident was first documented on 02/25/25 when one resident was found with two scratches on his left hand following a verbal altercation with his roommate. Initial interviews with both residents did not reveal the cause of the scratches, and the injured resident initially denied knowing how the injury occurred. The incident was not reported to the State agency until 03/03/25, several days after the initial documentation and after further interviews revealed that the resident had been in a fight with his roommate. The resident who sustained the scratches had a history of severe cognitive impairment, as indicated by a low BIMS score, and multiple medical diagnoses including dementia and traumatic brain injury. Medical records show that the scratches were superficial, with no active bleeding, and were treated according to physician orders. The roommate involved in the altercation was also documented as having dementia and behavioral disturbances, and was later transferred from the facility due to a psychiatric emergency following combative and aggressive behavior toward staff and other residents. Despite documentation of these behaviors and the altercation, the facility did not make timely notifications to the State agency or the ombudsman office as required by policy. Staff interviews revealed a lack of understanding regarding the requirement to report even verbal altercations as potential abuse. The Director of Nursing stated that they were unaware that a verbal altercation needed to be reported. The delay in reporting and incomplete notifications were contrary to the facility's own policy, which requires immediate reporting of suspected abuse, including resident-to-resident incidents, to the appropriate authorities within specified timeframes.