Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the local State Agency for two of four residents reviewed for abuse. According to the facility's Abuse Prevention Program Policy, all allegations or suspicions of abuse must be immediately reported to the administrator and the State Agency, and a thorough investigation must be conducted and documented. In this incident, one resident reported being kicked several times on the knees by another resident during an altercation in the dining room, which caused pain due to pre-existing knee problems. The altercation was witnessed by a CNA, who separated the residents and reported the incident to the administrator. Despite being informed of the incident, the administrator did not conduct a full investigation or report the event to the State Agency as required by policy. Only the resident who reported being kicked was interviewed, and no further follow-up or assessment of injuries was performed. The initial report to the State Agency was delayed, occurring several days after the incident rather than immediately as mandated. This failure to promptly report and investigate the abuse allegation resulted in noncompliance with both facility policy and regulatory requirements.