Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required. On the day of the incident, one resident was struck in the face by another resident while entering the dining room, resulting in a bleeding abrasion on the left side of the face. The injured resident, who was cognitively intact, reported the incident to staff, and the LPN on duty observed the injury and notified the Assistant Director of Nursing, the police, both residents' physicians, and family members. The resident who committed the act was sent to the hospital for psychiatric evaluation. Despite internal notifications and documentation of the incident, there was confusion among facility leadership regarding who was responsible for submitting the required report to the State Agency. The Administrator believed the DON was responsible, while the DON stated she was not able to submit the report due to being offsite and without computer access, and that the Administrator had agreed to handle it. Both parties referenced their usual practices for reporting but could not provide evidence that the report was submitted for this specific incident. Review of facility records and confirmation from the State Agency indicated that no report was received for the incident. The facility's own policy requires that all allegations of abuse involving injury be reported to the State Agency within two hours, with a final report submitted within five business days. For this incident, the initial and final reports provided by the facility were undated, untimed, and lacked any evidence of submission. The absence of confirmation documentation and the statements from both the Administrator and DON confirmed that the required reporting did not occur for this event.