Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse were reported immediately to the administrator and the state survey agency, as required by policy and regulation. An incident occurred in which one resident, with a history of dementia and other medical conditions, pushed another resident, who also had significant cognitive impairment, to the floor after a verbal altercation. The event was witnessed by staff, and the resident who was pushed complained of arm pain, but there was no immediate assessment by a licensed nurse, and no documentation of vital signs or neurological checks as directed by the medication technician. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the administrator or the state survey agency until four days after it occurred. Staff involved in the incident were unclear about their responsibilities for reporting, with some believing that the medication technician was a nurse and would handle the notification. The administrator and DON were not made aware of the incident until several days later, and there was confusion and lack of documentation regarding the required monitoring and assessment of the resident who was pushed. Medical record review confirmed that the resident who was pushed was not assessed by a nurse or had their family or physician notified until several days after the incident. The facility's investigation also revealed missing or undated documentation related to the required 15-minute checks and vital signs. The failure to report the incident in a timely manner and to follow established protocols for assessment and notification constituted a deficiency in the facility's abuse reporting procedures.