Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Agency as required by its own policy and federal regulations. An altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, which involved verbal and physical aggression, including yelling, swearing, threatening, and pushing mobility devices against each other. The incident was documented in the medical record, and one resident was subsequently moved out of the shared room. However, the Director of Nursing was not aware of the full extent of the altercation and confirmed that the incident was not reported to the State Agency. The facility's policy mandates that all allegations of abuse, neglect, or exploitation be reported to the State Agency and other authorities within specified timeframes, depending on the severity of the incident. Despite this, the altercation between the two residents was not reported, and there was no evidence of a report being made when requested by the surveyor. Interviews with both residents confirmed the occurrence of the altercation, and the Director of Nursing acknowledged the reporting failure during the survey.