Failure to Timely Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for one of four sampled residents. Specifically, an incident occurred in which two residents, both with cognitive impairments including dementia, were involved in a physical interaction over a box of gloves. One resident made contact with another's arm, witnessed by staff, and both residents were assessed with no injuries noted. The incident was documented and reported to the ombudsman and police, but not to the State Agency as required by regulations and the facility's own policy. Interviews with the Administrator and Director of Nursing revealed a misunderstanding of reporting requirements, as both believed that incidents involving residents with dementia and no injuries only needed to be reported to the ombudsman and police, not to the State Agency. Review of facility policy indicated that all alleged violations involving abuse must be reported to the State licensing/certification agency. The failure to report the incident to the State Agency resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from harm.