Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that an incident involving physical abuse between two residents was reported to the facility administrator and the State Agency as required by mandated reporting guidelines. According to the facility's Abuse-Neglect Prevention Manual, any evidence or suspicion of abuse must be reported immediately to the administrator or designee, who is then responsible for notifying the appropriate authorities. However, a review of facility-reported incidents over a one-month period revealed that no such incident involving the two residents was reported. Both residents involved in the altercation described a physical fight in the dining room, with one resident stating he was hit in the face and retaliated, and the other confirming the altercation and that staff were present. Interviews with staff confirmed that the altercation occurred, was witnessed, and was recognized as physical abuse, but there was no documentation in the residents' nurse's notes or care plans regarding the incident. Further interviews revealed that a CNA witnessed the altercation, intervened, and reported it to a nurse, but could not recall the specific date or the nurse's identity. An LPN also recalled being told about the incident by one of the residents but did not document or escalate the report. The Director of Nursing and the Administrator both confirmed that no staff reported the incident to them, despite acknowledging that such an event constitutes physical abuse and should have been reported immediately. The lack of internal reporting and absence of documentation resulted in the failure to notify the appropriate authorities as required by facility policy and state guidelines.