Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). Specifically, an incident involving two residents, where one resident entered another's room and grabbed their forearm, was not reported to the Department of Health and Senior Services (DHSS) as required by facility policy and state law. The facility's policy defines abuse and mandates immediate reporting of all allegations to the Administrator, DON, and appropriate authorities, with 'immediately' defined as within two hours. The incident in question involved a resident with diagnoses including dementia, PTSD, and major depressive disorder. This resident reported that another resident entered their room, grabbed their forearm, and only released after being asked. Staff intervened and assessed the resident for injury, initially finding none, but a subsequent assessment revealed a small bruise. Despite the resident reporting the incident to both the Administrator and Social Services Director (SSD), and expressing a desire to file a grievance, there was no documentation or evidence that the incident was reported to DHSS as required. Interviews with staff, including LPNs, CNA, SSD, and the Administrator, confirmed knowledge of the reporting requirement and the two-hour window for notification. However, staff either assumed the Administrator would report the incident or did not believe the incident warranted reporting due to the absence of visible injury at the time. The Administrator acknowledged being notified of the incident but chose not to report it, citing the lack of injury and no prior issues with the resident involved. DHSS records confirmed that the facility did not self-report the altercation or abuse allegation.