Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the state survey agency within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, an altercation occurred in which one resident hit another on the shoulder after being run into by a power wheelchair. The incident was witnessed by an LPN, who notified the Director of Nursing (DON) shortly after the event. The DON then contacted the Administrator (ADM), who was responsible for reporting abuse allegations to the state survey agency. Despite the policy requirements, the ADM submitted the abuse report to the state survey agency the following day, well beyond the two-hour window. Interviews revealed that both the DON and ADM were unclear about the correct reporting timeframe, with the DON believing the report was due within 24 hours and the ADM unaware that all abuse allegations required reporting within two hours, regardless of injury severity. Both residents involved had intact cognition and no behavioral symptoms documented during recent assessments.