Failure to Timely Report Suspected Abuse Following Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the Administrator and/or designee of a physical altercation between a staff member and a resident, resulting in a delayed report to the State Agency. The incident involved a resident with severe dementia, agitation, and mild cognitive impairment, who attempted to exit the memory care unit and became physically aggressive with a staff member. During the altercation, the staff member pushed the resident, causing the resident to fall and hit their head against the wall. The resident was subsequently transported to the emergency department for evaluation, but no acute behavioral issues were found upon return. Despite the seriousness of the incident, the initial reports from staff to the Director of Nursing (DON) did not accurately convey that the resident had been pushed by the staff member. The DON was informed that the resident had hit the staff member and then lost balance, leading to the fall. It was only five days later, after a review of camera footage prompted by another staff member, that it became clear the resident had been pushed. This delay in recognizing and reporting the incident as potential abuse resulted in the State Agency not being notified within the required two-hour timeframe. Facility policy mandates that all allegations or suspicions of abuse must be reported immediately to supervisors and the appropriate authorities, including the State Agency, within two hours if abuse is involved. In this case, the failure to communicate the true nature of the incident and to identify all witnesses led to a significant delay in reporting, contrary to facility policy and regulatory requirements.