Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported in a timely manner for two residents. According to facility policy, suspicions of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and other officials, with 'immediately' defined as within two hours for abuse or serious bodily injury, or within 24 hours for other allegations. On June 7, 2025, a housekeeper observed a possible inappropriate interaction between two residents and informed a nurse aide, who then witnessed one resident with her hand on another resident's penis. The nurse aide reported the incident to a registered nurse, who stated he was not the supervisor and directed her to inform the supervisor, but there is no evidence the supervisor was notified at that time. The manager on duty was informed by the nurse aide, but assumed the supervisor would handle the situation. The administrator was not made aware of the incident until two days later, on June 9, 2025. Interviews with staff revealed confusion regarding reporting responsibilities and a lack of clear communication, resulting in a delay in notifying the appropriate authorities about the alleged abuse. The nursing supervisor denied any knowledge of the incident, and the administrator confirmed she was not informed until after the required reporting timeframe had passed. The facility's failure to promptly report the alleged abuse as required by policy and regulation led to the deficiency.