Failure to Self-Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to self-report an incident involving two residents to the State Agency as required by policy. According to clinical record review, staff and resident interviews, and facility policy review, an altercation occurred in the dining room where one resident, who had cognitive impairment and a diagnosis of Alzheimer's Disease, was called a derogatory name by another resident, who then pulled the first resident's hair. This incident was witnessed by another resident, who reported it to the facility's social worker. The social worker, in turn, reported the event to the Administrator. Despite being informed of the incident, the Administrator did not report the altercation to the State Agency. The Administrator interviewed the involved residents, who did not recall the event, and contacted staff on the floor, none of whom had knowledge of the incident. The Administrator also decided not to interview the reporting resident due to concerns about her anxiety. The facility's policy requires immediate reporting of alleged violations related to mistreatment, neglect, or abuse, including resident-to-resident abuse, to the proper authorities, but this protocol was not followed in this case.