Failure to Report Resident-to-Resident Physical Incident to State Agency
Penalty
Summary
The facility failed to report a resident-to-resident physical incident to the State Agency as required. Two residents with significant cognitive impairments were involved: one with schizophrenia and anxiety, and another with Alzheimer's disease, depression, and dementia. The incident occurred when one resident approached another in the dining room, yelled, and struck her on the right upper arm. The event was witnessed by a Certified Occupational Therapist Assistant, who reported it to the nurse. The nurse completed an incident report and notified the Director of Nursing (DON) and Nursing Home Administrator (NHA). The interdisciplinary team discussed the incident and decided to send the resident who struck out to a psychiatric hospital. Despite internal documentation and discussion, the facility did not submit an initial report or a final investigation to the State Agency, as confirmed by a review of the Michigan Facility Reported Incident website. Interviews with staff revealed uncertainty about whether the incident was reported to the State Agency, and the facility's policy required such incidents to be reported. The lack of reporting resulted in an incomplete investigation and the potential for continued resident-to-resident incidents.