Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by law. Specifically, an incident occurred in which a male resident with PTSD, depression, and chronic systolic heart failure reported that another resident, who had dementia and was known to wander, entered his room and struck him on the forehead. The incident took place during the night, and although staff responded to the resident's call for help and performed skin assessments, the event was not reported to the facility administrator or DON until the following morning. The initial response by staff included redirecting the confused resident back to his room and conducting skin assessments, which revealed no physical injuries. However, the LVN who responded to the incident only notified the charge nurse and did not escalate the report to the administrator or DON as required. The administrator and DON were made aware of the incident during their morning meeting, several hours after the event. At first, the resident denied any physical contact, but later stated he had been hit, leading to confusion about the nature of the incident and whether it was reportable. The delay in reporting was further compounded by the fact that the administrator and DON did not receive timely notification from the night staff, and the incident was not reported to the state survey agency until more than 24 hours after it occurred. The facility's own abuse prevention policy and state guidelines require immediate reporting of such incidents, regardless of the presence or absence of injury. The failure to report the alleged abuse in a timely manner constituted a deficiency in the facility's compliance with abuse reporting requirements.