Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency. Specifically, an incident was identified in which a resident with a history of paranoid schizophrenia and schizoaffective disorder reported during a PASRR LA Update meeting that he had been assaulted by another resident in the secured unit, resulting in a bump on his head. The date of the alleged occurrence was unknown, and the resident stated that the facility would not call 911 or allow him to call 911. The allegation was documented in the PASRR Comprehensive Service Plan (PCSP) Form, but there was no evidence that the incident was reported to the State Survey Agency as required. Record review showed that a fax was sent to Health and Human Services with a brief narrative of the allegation, but there was no fax confirmation included, and the Texas Unified Licensure Information Portal did not reflect an initial self-report by the facility for the incident. Interviews with staff, including the ADON, CNA, RN, social worker, and psychiatric NP, revealed that none of them were aware of the allegation until it was brought to their attention by surveyors. The administrator confirmed he was not aware of the incident until shown the documentation and stated that the PASRR person should have reported it to him. Facility policy and staff interviews confirmed that all allegations of abuse, neglect, or exploitation should be reported immediately, regardless of the resident's history of making false allegations. Both residents involved had significant cognitive or psychiatric impairments, with one resident having moderate cognitive impairment and a history of mental illness, and the other having severe cognitive impairment due to dementia. Staff interviews indicated that they were trained in abuse, neglect, and exploitation (ANE) reporting and that regular in-services were conducted. However, the failure to report the allegation as required by policy and regulation constituted a deficiency, as it could place residents at risk of abuse, neglect, pain, and diminished quality of life.