Failure to Timely Report Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The facility failed to report a resident-to-resident altercation as potential abuse in accordance with its abuse prevention policy and state requirements. The incident involved a resident with moderate cognitive impairment and diagnoses including sciatica, Parkinsonism, and bipolar disorder, who was struck in the face and left flank area with a small pillow by their roommate. The event was documented in the nursing notes, and the Administrator, DON, NP, and the resident's POA were notified. However, the incident was not reported to the State Agency as required by the facility's policy and state regulations. The Administrator was aware of the incident and conducted an investigation but did not submit the required report to the Healthcare Facility Reporting System (HCFRS) at the time, as he initially believed no physical contact had occurred. It was later acknowledged by the Administrator that the incident should have been reported in accordance with the facility's investigation guidance and abuse policy. The failure to report was confirmed during interviews and review of the HCFRS, which showed the incident was not reported until 26 days after it occurred.