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F0609
D

Failure to Timely Report Resident-to-Resident Abuse

Broken Arrow, Oklahoma Survey Completed on 05-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to recognize and report an incident of potential abuse within the required two-hour timeframe for two residents involved in a resident-to-resident altercation. According to facility policy, all allegations of abuse, neglect, mistreatment, or misappropriation of resident property must be reported immediately, but no later than two hours after the allegation is made. In this case, an unwitnessed incident occurred in which one resident was found on the ground in another resident's room after staff heard a noise. The resident was assessed and found to have no injuries, while the other resident was sent for psychiatric evaluation. The incident was initially reported as an injury rather than abuse, and the Director of Nursing later acknowledged that it should have been recognized and reported as abuse within the required timeframe.

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