Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency as required by regulation. On the morning of the incident, staff heard yelling and found one resident in another resident's room, where the intruding resident was observed attempting to strike the other resident and his wife. The wife reported being struck, and the resident who was the target of the aggression was found with a red mark on his forehead, with later reports of facial bruising. Multiple staff witness statements confirmed the aggressive behavior, and the nurse on duty notified administrative staff, EMS, and law enforcement. However, the incident was not reported to the State Agency within the required timeframe. The facility's policy required notification of the State Agency within 24 hours of such incidents, or within two hours if the incident met the definition of a crime or resulted in serious bodily injury. Despite these requirements and the presence of physical evidence of injury, administrative staff did not report the incident to the State Agency. Interviews confirmed that the administrative staff was aware of the reporting requirements but failed to comply, resulting in a deficiency related to the timely reporting of suspected abuse.