Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving two residents to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's own Abuse Investigation and Reporting policy. The incident occurred when one resident alleged that another resident hit him on the leg, and law enforcement was called to the facility. The facility became aware of the abuse allegation at approximately 5:30 AM, but the report to the state survey agency was not made until 9:09 AM, exceeding the mandated two-hour reporting window. Interviews with staff confirmed awareness of the reporting requirement and acknowledged the delay in notification. The resident who made the allegation had a history of heart failure, diabetes mellitus, and cystitis, and was dependent on staff for personal care, with intact cognitive ability. The other resident involved had diagnoses including a left thigh fracture, heart failure, and diabetes mellitus. The facility's policy required immediate reporting of abuse allegations, especially those involving abuse or resulting in serious bodily injury, but this protocol was not followed in this instance, as evidenced by the delayed fax confirmation of the report.