Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of resident property were reported to the State Survey Agency within 24 hours as required. Specifically, an incident occurred in which one resident pushed or hit another resident in the chest area while passing in the hallway. The incident was reported to the charge nurse by the affected resident, and the Administrator (ADM) was informed on the same day. However, the ADM delayed reporting the alleged abuse to the Health and Human Services Commission (HHSC) until three days after the incident, despite being responsible for timely reporting. The delay occurred as the ADM was conducting an internal investigation and receiving conflicting accounts from the residents involved. Both residents involved had significant medical histories, including end stage renal disease, hypertension, osteoarthritis, cerebral infarction, type 2 diabetes, and vascular dementia. One resident was cognitively intact, while the other had moderate cognitive impairment. Interviews with both residents indicated that neither felt unsafe or injured after the incident, and both described the event as a push to get by in the hallway. The Director of Nursing (DON) confirmed that it was the ADM's responsibility to report such incidents promptly to prevent further abuse, and the ADM acknowledged the failure to report within the required timeframe.