Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state agency as required by its abuse, neglect, and exploitation policy. One cognitively intact resident, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 on a quarterly MDS dated 04/21/25, struck another resident on 06/30/25. Progress notes and risk management documentation for that date indicated that this resident struck another resident with an open hand while lying in bed. The other resident involved had severe cognitive impairment, with a BIMS score of 4 out of 15 on an annual MDS dated 04/21/25, and was standing next to the first resident’s bedside attempting to calm or comfort her when the strike occurred. Progress notes and risk management notes for the cognitively impaired resident documented that the resident was slapped on the cheek or hit in the face with the back of the hand while trying to comfort the other resident. During interviews, an LPN confirmed that the cognitively intact resident smacked the cognitively impaired resident on the face with her left hand while in bed. The DON and the Regional Corporate Consultant both confirmed that this incident was not reported to the state agency. The Administrator stated that he believed the incident was accidental. The facility’s abuse, neglect, and exploitation policy dated 09/12/24 stated that the facility will report all alleged violations and all substantiated incidents to the state agency and other required agencies, but this allegation was not reported as required.
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