Failure to Timely Report Alleged Staff Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to timely report multiple allegations of abuse and a resident-to-resident altercation within the required immediate, not more than 24-hour timeframe. In the first incident, a CNA (V3) reported that another CNA (V4) hit a cognitively impaired resident (R2) with a positioning cushion and stated, "I hate you." The facility’s investigation report shows the alleged event occurred on 10/27/25, but the allegation was not brought to facility leadership until 11/10/25. V3 later stated she witnessed the incident on 10/27/25 but delayed reporting it for about a week because she was a new employee and feared backlash from other staff. V3 had previously signed a Training Acknowledgement Form stating it was her responsibility to immediately report any signs of abuse, neglect, or mistreatment to her supervisor and the administrator, and to report any observed, heard about, or suspected mistreatment immediately. In the second incident, staff failed to immediately report a resident-to-resident verbal altercation in which one resident (R3) threatened to beat another resident (R4). The facility’s investigation report documents that the altercation occurred on 11/29/25 and was witnessed by a CNA (V5) and an RN (V6). The administrator (V1) and DON (V2) did not learn of the incident until they read an RN progress note in the electronic medical record on 12/1/25. V5 acknowledged witnessing the altercation, separating the residents, and reporting it only to the nurse on duty, and did not notify the administrator or the on-call manager. V2 confirmed that neither V5 nor V6 contacted her over the weekend to report the incident. V5 had also signed a Training Acknowledgement Form stating that any alleged violations involving mistreatment, neglect, or abuse must be reported immediately to a supervisor and the administrator. The facility’s abuse prevention policy states that all allegations or suspicions of abuse will be reported in the proper timeframe.
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