Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency within the required timeframe. Specifically, an incident occurred in which one resident, who had a history of Huntington's disease and severely impaired cognition, was punched in the arm by another resident with a diagnosis of alcohol-induced dementia and psychosis disorder. The incident was witnessed by an LVN, who immediately separated the residents and reported the event to the DON, ADON, and the administrator. Resident assessments following the incident revealed no injuries or pain, and the event was documented in the facility's records. Despite the facility's policy defining physical abuse as including hitting and requiring immediate reporting of such incidents, the event was not reported to the state agency within the mandated two-hour window. The DON and administrator were both notified of the incident and conducted an internal investigation. During this process, the resident who was punched denied being hit and described the event as the other resident moving her arm out of his face. Based on this information and after consultation with a corporate nurse, the decision was made not to report the incident as abuse to the state agency. A review of the Texas Unified Licensure Information Portal confirmed that no self-reported incidents regarding allegations of abuse were submitted for the resident involved. Both the DON and administrator acknowledged during interviews that, according to facility policy, the incident should have been reported as an alleged physical abuse event to the state agency within two hours, regardless of the internal investigation's findings. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.