Failure to Report Resident-to-Resident Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of physical abuse to the State Agency as required by regulation. On 10/27/25, one resident approached another from behind in a common area, struck the individual in the head and neck, knocked them to the floor, and proceeded to kick and stomp on their head and body multiple times. The assaulted resident sustained bruising, minor swelling, and a scratch, and was attended to by facility nurses. Law enforcement was notified, and the aggressor was taken into custody and charged with assault. The incident was documented in progress notes and a facility investigation, and the victim's guardian was later informed. Despite the severity of the incident and the physical injuries observed, the facility leadership, including the DON, Regional Director of Operations, Regional Nurse Consultant, and Administrator, did not consider the event to be abuse. Their rationale was based on their interpretation that abuse requires malicious intent or significant injury, and they believed the aggressor's mental state or possible intoxication made the behavior unpredictable rather than willful. As a result, the team decided not to report the incident to the State Agency, even though the facility's policy and the State Operations Manual require reporting of such events within 24 hours if they are deemed reportable. Interviews with facility staff and consultants revealed a consistent misunderstanding or misapplication of the definitions of abuse and reportable events. Several staff members stated that, in their view, the absence of serious injury or clear malicious intent meant the incident was not reportable. The guardian of the assaulted resident expressed concern about not being fully informed and indicated that, had they known the extent of the incident, they would have requested further medical evaluation. The facility's failure to report the incident as required constitutes the identified deficiency.