Failure to Protect Residents from Abuse and Timely Reporting of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, neglect, and misappropriation of property, as evidenced by two separate resident-to-resident altercations involving four residents. In the first incident, a resident with severe cognitive impairment and a history of schizophrenia and dementia struck another resident, who had intact cognition, on the upper shoulder and neck. The event was witnessed via video surveillance, and both residents were assessed with no injuries found. The incident was reported to the appropriate parties, but there was confusion among staff and administration regarding the required timeframe for reporting such events, with the administrator and staff referencing outdated guidance and facility policy that did not specify the current regulatory requirement for reporting within two hours. In the second incident, two residents, both with cognitive impairments and histories of dementia and psychiatric disorders, engaged in a physical altercation over a towel in the dining room. One resident sustained a skin tear with scant bleeding to her hand, which was treated by nursing staff. Both residents were separated, assessed, and notifications were made to the physician, DON, and administrator. Video surveillance and staff interviews confirmed the altercation, but there was again a lack of clarity among staff and administration regarding the classification of the event as abuse and the appropriate reporting timeframe. The facility's policy did not provide a specific timeframe for reporting, and staff relied on their understanding of previous guidance, which was not aligned with current regulations. Throughout both incidents, staff and administration demonstrated inconsistent understanding of abuse reporting requirements, particularly regarding the two-hour reporting window for allegations of abuse. Training records indicated that staff had received education on abuse, neglect, and exploitation, but interviews revealed gaps in knowledge about current regulatory expectations. The facility's policy referenced following applicable regulations but did not specify the required reporting timeframe, contributing to the deficiency.