Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident occurred in which a resident with severe cognitive impairment and aphasia was slapped in the face by another resident, who also had severe cognitive impairment. The incident was witnessed by an LVN, who immediately separated the residents and notified the Director of Nursing (DON), Administrator, physician, and both residents' responsible parties. Documentation in the progress notes confirmed the incident and the actions taken at the time. Despite these actions, the incident was not reported to the State Survey Agency as required by federal regulations. The DON and Administrator stated during interviews that they did not report the incident because they believed there was no willful intent from the resident who committed the act, citing the resident's BIMS score of 0 and lack of prior behavioral issues. A review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no report corresponding to this incident was submitted. The facility's policy required investigation and reporting of any allegations within the federally mandated timeframes, which was not followed in this case.