Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident occurred involving two residents, both with dementia and cognitive impairment, where one resident struck the other with a hairbrush, resulting in visible injuries such as bruising and skin tears. Despite the incident being documented in nursing notes and witnessed by staff, the event was not reported to the state survey agency or other required authorities within the mandated timeframe. The records show that the resident who was struck had a history of vascular dementia and moderate cognitive impairment, while the resident who struck her had severe cognitive impairment and a history of behavioral symptoms. Staff documented the injuries, separated the residents, and notified responsible parties and the nurse practitioner, but the administrator decided not to report the incident to the state agency. The administrator cited the aggressor's severe cognitive impairment and lack of intent as the reason for not reporting, referencing a provider letter and facility policy, despite the policy stating that cognitive impairment does not preclude a resident from engaging in deliberate or non-accidental behavior. Interviews with staff and review of facility policy confirmed that the incident met the criteria for abuse reporting, as it involved a willful action resulting in physical injury. The facility's own policy and regulatory guidance require immediate reporting of such incidents, regardless of the cognitive status or intent of the resident involved. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.