Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents, as required by its Abuse Prevention Policy and Procedure. The policy mandates that any incident involving alleged mistreatment, neglect, exploitation, or abuse, including injuries of unknown source, must be immediately reported to the appropriate authorities, including the state survey agency. On the date in question, a nurse's note documented that one resident was "throwing punches" with another resident. Both residents later confirmed in interviews that a physical altercation occurred, with one resident stating he hit the other in the face after being accused of taking money. Staff intervened and separated the residents at the time of the incident. Despite the clear documentation and resident admissions of a physical altercation, the incident was not reported to the state survey agency as required. The Director of Nursing stated that abuse was not suspected and therefore the incident was not reported within the mandated two-hour timeframe. Additionally, the DON confirmed that interviews with the residents were not conducted within two hours of the incident, and the event was not entered into the facility's reportable logs. This failure to report had the potential to affect all residents receiving care in the facility.