Failure to Timely Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including resident-to-resident altercations—were reported to the administrator and State Survey Agency within the required timeframes. Specifically, the facility did not report two separate resident-to-resident altercations within two hours as required by regulation. In the first incident, two female residents were involved in an altercation in the hallway, with one resident alleging she was hit by the other. Both residents were assessed and found to have no injuries, and notifications were made to the medical doctor, responsible parties, DON, and administrator. However, the self-report to the state was not submitted until more than two hours after the incident occurred. In the second incident, two other female residents were involved in a physical altercation in the dining room over a towel, resulting in a skin tear to one resident's hand. Both residents were separated, assessed, and notifications were made to the appropriate parties. The incident was not reported to the state within the required two-hour timeframe, as the self-report was submitted more than two hours after the event. Interviews with staff and the administrator revealed a lack of clarity and training regarding the specific two-hour reporting requirement for abuse allegations, with some staff and the administrator believing that a 24-hour timeframe was sufficient if there was no major physical injury. The residents involved in these incidents had varying degrees of cognitive impairment, as indicated by their BIMS scores and diagnoses such as dementia, schizophrenia, and bipolar disorder. Despite the absence of significant injuries and the residents' own reports of feeling safe, the facility's failure to report these altercations within the mandated timeframe constituted a deficiency. The facility's abuse policy did not specify the required reporting timeframe, and staff training records indicated that while abuse and neglect training had been provided, there was confusion about the regulatory requirements for timely reporting.