Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two residents. One resident, who had a history of dementia, schizophrenia, neurogenic bladder, and PTSD, and was assessed as having mild cognitive impairment, became agitated and physically struck another resident in the face after a verbal altercation. The incident occurred in a common area and was witnessed by nursing staff, who intervened to separate the residents. The facility's policy requires that allegations of abuse be reported immediately, but not later than two hours after the event if it involves abuse or results in serious bodily injury. Despite the policy, the incident was not reported to the State Agency until nearly two days later. The delay occurred because the charge nurse attempted to notify the Administrator shortly after the incident, but the Administrator did not respond until several hours later, citing personal errands. Additionally, the Interim DON had quit via text message on the day of the incident, contributing to the communication breakdown. The Administrator acknowledged that the late reporting was her responsibility and that the charge nurse had attempted to follow proper procedures.