Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or exploitation, as required by regulations. Specifically, the facility did not report a resident-to-resident physical altercation to local law enforcement, nor did it report an allegation of staff-to-resident verbal abuse within the mandated two-hour timeframe. These failures were identified through interviews and record reviews for two residents out of ten reviewed for abuse/neglect reporting. In the first incident, a male resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in a physical altercation with another male resident who had moderate cognitive impairment. The altercation resulted in minor injuries, including discoloration to the hands and an abrasion to the chin. Although the incident was documented and the residents were monitored, the Assistant Director of Nursing (ADON) did not report the event to local authorities, stating she did not consider it abuse due to both residents' mental illnesses and the belief that the act was not willful. There was no evidence or case number to show that the incident had been reported as required. In the second incident, a female resident with intact cognition and hemiplegia was subjected to inappropriate comments by a nursing assistant, including remarks about her weight and sexual orientation. The certified nursing assistant who witnessed the event did not report it immediately, assuming another staff member present would do so. The Director of Nursing and Administrator confirmed that the incident was not reported to the state agency until several days later, after the ombudsman became involved. The facility's policy requires immediate reporting of all alleged violations, but this protocol was not followed in these cases.