Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of resident-to-resident abuse to the state agency for two residents. One resident, who had a diagnosis of neurocognitive disorder with dementia, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. This resident engaged in aggressive behavior at the nurses' station, where he grabbed another resident's walker, yelled, pushed, and struck the other resident multiple times in the chest and shoulder before staff could intervene. The second resident, who had a history of cerebral infarction and was identified as potentially verbally aggressive, sustained injuries including pain and a lump on her right shoulder and bicep as a result of the incident. Despite facility policy requiring immediate reporting of suspected maltreatment to the state agency, the incident was not reported in a timely manner. The social service designee completed an internal report promptly but did not notify the correct agency. The administrator confirmed that the incident was not reported to the state agency until it was identified by a corporate consultant, which was not within the required timeframe outlined in facility policy.