Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred involving two residents in which one resident threw cold coffee at another, and the second resident responded by hitting the first, resulting in a bruise beneath the eye and a scratch on the arm of the first resident. Despite staff recognizing the incident as a resident-to-resident altercation and a form of abuse, the event was not reported to the state survey agency as required. The first resident involved had a history of Parkinson's Disease, schizoaffective disorder, and bipolar disorder, but was assessed as having no cognitive impairment. The second resident had severe cognitive impairment due to dementia and a history of physical aggression. After the altercation, staff immediately separated the residents, assessed them for injuries, and initiated neuro checks for the resident who sustained a facial bruise. Both residents were interviewed and assessed for pain and psychological distress, with the first resident reporting ongoing pain in the face but no distress at the time of assessment. Multiple staff members, including RNs and LVNs, acknowledged in interviews that the incident constituted abuse and that it was their practice to report such events to the administrator. However, the administrator did not report the incident to the state survey agency, stating that he did not consider the event to be abuse or neglect because the injury did not require first aid and the resident did not appear distressed. This failure to report the incident as required by state law and facility policy constituted a deficiency in the facility's abuse reporting procedures.