Failure to Timely Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the state agency as required by policy. The incident involved one resident entering another's room and going through personal belongings, which led to a physical altercation where one resident punched the other in the face. Both residents were assessed to have no cognitive impairment, and neither sustained injury or required hospitalization. Staff interviews confirmed that the altercation was witnessed and reported internally, but no external report was made to the state agency or law enforcement at the time of the incident. The administrator initiated a preliminary internal investigation but chose not to report the incident externally, citing a desire to confirm the facts before making a report. The facility's policy requires immediate reporting of all alleged violations involving abuse to the administrator, state agency, and other required agencies within specified timeframes. Despite this, the administrator acknowledged that the incident should have been reported within two hours, as it involved physical abuse between residents. Interviews with nursing staff and the CNA present at the time corroborated the sequence of events and the lack of external reporting. Both residents involved expressed their perspectives on the incident, with one admitting to the physical act and the other acknowledging the provocation. The facility's failure to follow its own abuse reporting policy resulted in a deficiency related to timely reporting of suspected abuse to the appropriate authorities.