Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required by facility policy and state law. Specifically, staff documented two resident-to-resident altercations involving two residents, but these incidents were not reported to the State Agency, and one was not reported to the administrator. The facility's abuse prohibition policy requires immediate reporting of such allegations, but this procedure was not followed in these cases. Documentation showed that after supper, one resident exhibited aggressive behaviors, including yelling at another resident and throwing an object in their direction. The same resident also threatened another by slamming her walker into a chair and making a verbal threat. The LPN who documented the events reported only one of the incidents to the administrator and was uncertain about reporting the other. During interviews, both the LPN and the administrator acknowledged that these events should have been reported as allegations of abuse to both the administrator and the State Agency, but this did not occur.