Failure to Provide Sufficient Details in Abuse Reporting
Penalty
Summary
The facility failed to provide a report with sufficient information regarding an alleged incident of physical abuse between two residents to the State Agency and the Long Term Care Ombudsman. On the date of the incident, a CNA discovered one resident with blood stains on his face and hands, and the situation was immediately reported to the charge nurse. Emergency services, including 911, police, hospice, physicians, the state health department, the Ombudsman, and the family, were notified, and the injured resident was transferred to the hospital. Documentation indicated that the resident had dementia, impulse disorder, and was receiving hospice care, and did not have the capacity to make decisions. The other resident involved, who also had dementia and a history of being a registered sex offender on parole, was found in the same room, covered with a sheet, and initially refused assessment. Police interviewed this resident, who admitted to hitting the other resident due to noise. The resident was then taken into custody by law enforcement. Both residents had no prior history of aggressive behavior toward each other, and the incident was unwitnessed. A review of the SOC 341 form faxed to the authorities revealed that it lacked pertinent details about the alleged abuse, only stating "allegation" without describing the event, time, or names of those involved. Interviews with facility staff, including an RN and the Administrator, confirmed that the form was incomplete and did not meet the facility's policy requirements for reporting abuse, which specify that detailed information must be included to inform agencies and advocates about the incident.