Failure to Timely Report Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to report an allegation of possible physical abuse between two residents to the State Survey Agency (SSA) within the required two-hour timeframe. The incident involved one resident throwing a spoon at another during lunch, followed by a physical altercation in which one resident pushed the other, resulting in both residents falling to the floor. The event was witnessed by a family member and staff, and both residents were assessed for injuries, with none observed. However, there was no documentation that the incident was reported to the Department of Health and Senior Services (DHSS) as required by facility policy and state regulations. Both residents involved had severe cognitive impairment and diagnoses including Alzheimer's disease, with one resident also having sick sinus syndrome. Their care plans did not address any prior history of resident-to-resident altercations. Staff responded to the incident by separating the residents, assessing them for injuries, and notifying their families and physicians. Despite these actions, the required notification to DHSS was not completed or documented. Interviews with staff, including CNAs, a CMT, an LPN, the DON, and the Administrator, revealed inconsistent understanding of the reporting requirements. Some staff believed that reporting to DHSS was required within 24 hours, while others stated it should be done within two hours. The DON and Administrator both acknowledged that the incident should have been reported to DHSS, but neither completed the report, with the Administrator stating he believed it was not necessary if both residents were confused and there was no harm. This failure to report the incident constituted a deficiency in timely reporting of suspected abuse as required by policy and regulation.