Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse as required by its own abuse policy and regulatory standards. On the date of the incident, a resident with severe cognitive impairment and a history of physical aggression slapped another resident in the dining room, knocking off her glasses and reportedly pulling her hair. The victim, who also had severe cognitive impairment and multiple diagnoses including seizure disorder and dementia, was later found to have a scratch and subsequently developed an abscess near her eye, which required antibiotic treatment. Staff documented the incident and separated the residents immediately, but did not report the event to the state agency or other required authorities within the mandated timeframe. Clinical record review, staff interviews, and facility policy review confirmed that the incident met the facility's definition of abuse and should have been reported. The facility's abuse policy required immediate reporting of all alleged violations involving abuse, but nursing staff failed to inform the nurse practitioner of the incident at the time of her visit and did not notify the appropriate authorities. Both the administrator and the director of nursing later acknowledged that the incident should have been reported according to policy.