Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Reporting Policy by not reporting an allegation of resident-to-resident physical abuse within the required two-hour timeframe. On the night in question, one resident was physically attacked by her roommate, who hit her multiple times, threw objects at her, and attempted to strike her with a cane. The incident was witnessed by multiple staff members, including a Certified Nurse Assistant and an Agency-Certified Nurse Assistant, who intervened to separate the residents. Despite the severity of the incident, including the involvement of law enforcement and the removal of the aggressor to a hospital for psychiatric evaluation, the event was not reported to the appropriate authorities within the mandated period. Interviews with staff revealed a lack of immediate recognition and reporting of the abuse. The Certified Nurse Assistant present did not report the altercation, perceiving it as minor arguing, while the Agency-Certified Nurse Assistant confirmed witnessing physical violence. The Director of Nursing and Administrator were not fully informed of the extent of the incident until several days later, and the required report to the state agency was delayed. The facility's policy clearly defines immediate reporting as within two hours, but this protocol was not followed, resulting in a delay in notifying authorities about the abuse allegation.