Failure to Timely Report Alleged Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls was admitted and later discharged after sustaining injuries. Hospital documentation indicated that the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was uploaded to the resident's electronic medical record several days after the incident. A review of the facility's Self-Reported Incidents (SRI) logs showed no record of the abuse allegation being reported to the State Survey Agency during the relevant period. Interviews with the Administrator and DON confirmed they were unaware of the abuse allegation and that it had not been reported as required. The facility's policy mandates immediate reporting, or no later than two hours after an allegation is made, but this was not followed in this case.