Failure to Immediately Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours, as required. Specifically, an incident occurred in which one resident stomped or kicked another resident's foot, resulting in a bruise. The incident was witnessed by a CNA, who reported it to an RN, but neither the CNA nor the RN reported the incident to the Administrator (ADM) immediately. The ADM was not notified of the incident until the following day, well beyond the required reporting timeframe. The resident who was the victim of the incident had a history of schizoaffective disorder, autism, and cognitive communication deficits, with moderately impaired cognition. The resident who committed the act had a history of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms directed at other residents. The incident was documented in event reports by the RN, and the victim was assessed and found to have a bruise but denied pain or discomfort. The perpetrator admitted to the act during an interview, stating it was done out of meanness. Interviews with staff revealed that the CNA and RN involved were aware of the requirement to report abuse but did not notify the ADM as required. The RN stated she had not received training on abuse reporting at the time of hire and was unaware of the requirement to notify the ADM. However, training records indicated that required abuse and neglect training had been completed by the staff involved. Facility policy required immediate reporting of suspected abuse to the administrator and other officials according to state law and guidelines.