Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving two residents engaged in a physical altercation was reported to the State Agency (SA) immediately, but no later than two hours as required. The incident involved a verbal altercation escalating to one resident allegedly striking another in the face, resulting in injuries including a dislocated jaw and chest wall contusion. Documentation showed that both residents were cognitively intact, with one having a recent history of verbal behaviors. The incident occurred late in the evening, but the report to the SA was not submitted until several days later. Interviews with staff revealed confusion and lack of awareness regarding the correct abuse reporting procedures. One LPN reported the incident only to the DON, not to the administrator or the SA, while another LPN was unaware of how to report to the SA and referenced unclear instructions. The DON and administrator both acknowledged that abuse allegations should be reported to the SA within two hours, but this protocol was not followed due to staff not being properly informed and the incident occurring over a weekend. The facility's policy required immediate reporting of alleged abuse, but this was not adhered to in this case.