Failure to Timely Report Peer-to-Peer Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of peer-to-peer abuse to the Administrator, as required by policy. One resident with severe cognitive impairment reported that another resident, who also has a history of adverse behaviors and severe cognitive deficits, entered her room and hit her. Another resident, who is cognitively intact, corroborated that the alleged aggressor entered the room and was physically aggressive. Staff interviews confirmed that the resident in question is known to be physically combative and has a pattern of wandering into other residents' rooms, sometimes becoming aggressive. Despite these reports and observations, there was no documentation in the residents' progress notes or in the facility's abuse/neglect allegation records regarding this specific incident of peer-to-peer aggression. Staff members, including CNAs and an LPN, were aware of the incident, with one LPN responding to a call for help and finding the alleged aggressor in the room. The LPN and a CNA both documented that the resident who was allegedly hit denied being struck but wanted the other resident removed from her bed. However, the incident was not reported to the Administrator until the surveyor brought it to their attention. The facility's Abuse Prevention Training Program requires that all allegations of potential abuse, neglect, or mistreatment be reported immediately to the Administrator. In this case, the failure to report the incident in a timely manner resulted in a delay in initiating an investigation and notifying the appropriate authorities, as required by facility policy and regulatory standards.