Failure to Timely Report Resident-on-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-on-resident physical abuse to the State Agency within the required timeframe, as mandated by federal regulations. On the evening of 6/09/25, a certified nursing assistant (CNA) witnessed one resident strike another near the vending machines and immediately reported the incident to a registered nurse (RN) and a licensed practical nurse (LPN). The incident was also communicated to the Social Services Director (SSD) and the facility Administrator by the following day. Despite internal investigation and staff awareness, the allegation was not reported to the State Agency as required by facility policy and federal law. Interviews with staff confirmed that the incident was observed, reported, and discussed among multiple staff members, including the SSD, DON, and Administrator. The Administrator acknowledged awareness of the incident but chose not to report it to the State Agency, citing ongoing incidents between the two residents and a denial from the alleged victim during an interview. Documentation in the progress notes for the alleged perpetrator did not reflect the incident until nearly two weeks later, and the facility's investigation records confirmed that an internal review was conducted starting on the date of the incident. Both residents involved had a history of ongoing altercations and were known to seek each other out despite interventions such as room changes. The resident alleged to have committed the abuse had diagnoses of hemiplegia and diabetes, with no cognitive impairment per the most recent MDS. The alleged victim had chronic kidney disease, heart failure, and fluctuating cognitive status, with recent MDS scores indicating moderate to no cognitive impairment. The facility did not implement one-on-one supervision or other measures to ensure resident safety at the time of the incident.