Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency in a timely manner for two residents with moderately impaired cognition. One resident, with a history of verbally abusive and sexually inappropriate behaviors, was observed by an LPN student with their hand under another resident's shirt, touching the upper chest area. The LPN student intervened by stopping the behavior, moving the affected resident away, and notifying the charge nurse. Facility documentation classified the incident as a Class E and implemented internal interventions, but did not report the event to the State Agency as required. The Director of Nursing (DON) stated that the incident was not reported because it was witnessed, there was no intention of harm, no injuries occurred, no signs of distress were observed, and families did not express concerns. However, the facility's own abuse policy defined sexual abuse to include unwanted touching between residents and required notification of the Department of Public Health and submission of an online report within two hours. Review of the State's event tracking system confirmed that the incident was not reported as mandated.