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 no later than 2 hours after the allegation was made, as required by federal regulations. Specifically, an allegation of abuse was made by one resident against another during a phone call with her daughter, which was overheard by a registered nurse. The nurse did not immediately report the allegation to the Nursing Home Administrator (NHA) or Director of Nursing (DON), and there was no documentation of immediate notification to facility leadership regarding the incident. The resident who made the allegation had a history of cerebral infarction, a closed fracture of the distal end of the left radius, and dementia. The accused resident also had a history of stroke and dementia. The incident involved the first resident expressing discomfort about another resident holding her hand and making unwanted advances, which she relayed to her daughter and was overheard by staff. Despite this, staff did not observe any physical resistance or discomfort prior to the phone call, and there was no documentation in the accused resident's chart regarding the incident. Interviews with staff revealed a lack of timely education and awareness regarding abuse reporting requirements. Several staff members, including registered nurses and certified nursing assistants, indicated that they had only recently received or signed off on abuse reporting education, some on the day of the survey. The DON and NHA also provided inconsistent information about the reporting timeframe, with the DON stating a 24-hour window if there was no immediate danger or injury, contrary to the facility's policy and federal requirements for 2-hour reporting in cases involving abuse.