Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two cognitively intact residents who were involved in a physical altercation. According to the records, one resident was observed by a Certified Nursing Assistant (CNA) to be hitting another resident in the upper chest and collarbone area while the other resident was lying in bed in a defensive posture. The CNA immediately intervened and separated the residents. Statements from multiple staff members, including the CNA and a Registered Nurse (RN), confirmed that the incident involved physical contact, with the CNA consistently stating she witnessed one resident hitting the other. Despite these observations, the Nursing Home Administrator (NHA) was initially informed that the incident was only a verbal argument. The NHA did not receive or document clear information about the physical nature of the altercation until after further investigation the following day. The facility's own policy requires that allegations of abuse be reported to the Administrator, state agency, and other required authorities immediately, but no later than two hours after the allegation is made. However, the incident was reported to the state survey agency approximately 17 hours after it occurred. The delay in reporting was compounded by inconsistent communication and documentation. The NHA did not document a follow-up conversation with the CNA, who maintained her original statement about witnessing physical abuse. Additionally, the NHA did not have the CNA revise her statement to reflect any uncertainty, as claimed during the investigation. The facility's failure to promptly and accurately report the abuse allegation as required by policy resulted in a deficiency.