Failure to Timely Report Abuse, Neglect, and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported to the appropriate authorities within the required timeframes. Specifically, three out of five reportable incidents were not reported as mandated. One resident eloped from the facility, and two separate resident-to-resident altercations occurred, but none of these incidents were reported to the State Agency as required by regulations. Interviews with staff revealed inconsistencies in training and knowledge regarding the reporting and management of resident-to-resident altercations. While a CNA indicated awareness of the need to deescalate and report such incidents immediately, an LPN stated she had not received recent training on this topic. An RN reported having received training and posted relevant materials at a nurses' station, but also noted that further education was planned. These findings indicate that the facility did not consistently follow established procedures for timely reporting of incidents involving potential abuse or neglect.