Failure to Timely Report Alleged Resident-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to required local, state, and federal authorities within two hours, as required by facility policy. Two residents were involved in the alleged incident. One resident had chronic respiratory failure, unspecified dementia, and peripheral vascular disease, and was documented in a recent H&P as lacking capacity to understand and make decisions, while a later MDS showed modified independent cognitive skills for daily decision-making and a need for assistance with activities of daily living. The second resident had unspecified dementia, type 2 DM, and peripheral vascular disease, was documented in an H&P as lacking capacity to understand and make decisions, and was assessed on the MDS as having severely impaired cognitive skills and being dependent or needing assistance for most ADLs. On a Sunday, CNA 1 observed an interaction in the activity/dining room and stated it looked as if the second resident struck the first resident. CNA 1 reported that on the day of the alleged incident, an LVN said she would make a report, but CNA 1 did not report the alleged incident to the Administrator or any other facility staff that day. LVN 1 later stated she was informed by a CNA the day after the alleged incident that the second resident allegedly slapped the first resident. The Director of Staffing informed the DON and Administrator of the alleged incident several days later, at which time the DON spoke with CNA 1, who reported that the two residents allegedly hit each other in the activity room. The Administrator acknowledged that the alleged incident occurred on a Sunday and that he was not informed until several days later, after which he investigated the incident internally without reporting it to any outside agencies. The DON stated the facility did not report the alleged incident of abuse because it was investigated within the facility and there was no evidence that it occurred, but also stated that alleged hitting or slapping of a resident is considered abuse and, per facility policy, should have been reported within two hours to the appropriate agencies. The facility’s written policy on abuse, neglect, exploitation, or misappropriation requires that any suspicion of abuse be immediately reported to the Administrator and to specified external agencies, defining “immediately” as within two hours of an allegation involving abuse. Despite this policy, the facility did not report the allegation involving these two residents to the State Survey Agency, APS, law enforcement, or other listed entities.
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