Failure to Report Resident-to-Resident Incident Resulting in Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident incident to the appropriate state agencies as required by law. A resident with severe cognitive impairment and multiple diagnoses, including anoxic brain damage and aphasia, was observed with significant bruising and swelling around her left eye. Documentation and staff interviews revealed that another resident mistakenly entered her bed, resulting in physical contact between the two residents' heads. The incident was witnessed by staff, and both residents were assessed, with the affected resident later showing visible injury. The incident was documented in progress notes and communicated to the families of both residents. Despite the presence of injury and the facility's own policy identifying physical marks as possible indicators of abuse, the DON and NHA did not report the incident to state agencies or law enforcement. The DON stated that the event was not considered reportable because there was no intent or physical aggression involved. This decision was made even though the facility's policy requires reporting all alleged violations, including those resulting in injury, within specified time frames.