F0609

D

Failure to Timely Report Resident-to-Resident Physical Abuse Allegations to DHSS

Wright City, Missouri Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Facility staff failed to timely report two separate allegations of resident-to-resident physical abuse involving one resident to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe, as required by the facility’s Abuse Prevention Policy dated 11/28/2016. The policy states that all alleged violations involving abuse, including resident-to-resident physical altercations such as hitting, slapping, punching, biting, and kicking, must be reported immediately, but no later than two hours after the allegation is made. On 12/18/25, progress notes documented that a resident with moderate cognitive impairment, dementia, Alzheimer’s disease, difficulty speaking and understanding others, and independent ambulation was banging on exit doors, was redirected, then began pacing the hallway where another resident was walking. The cognitively impaired resident grabbed the other resident and hit him/her multiple times, prompting the other resident to hit back. Staff separated the residents, assessed them with no injuries and no pain, placed the aggressor on 15‑minute checks, notified management on call, the physician, and responsible party, and sent the aggressor to the emergency room for evaluation. However, no initial report was submitted to DHSS within two hours. The administrator later stated he/she was not aware of the 12/18/25 incident and acknowledged it should have been reported within two hours, while LPN A and LPN B both stated they knew such incidents must be reported within two hours but each believed the other or management would complete and submit the report.

A second incident occurred on 01/07/26 involving the same aggressor resident and another resident assessed as cognitively intact, with diagnoses including cognitive deficits following a nontraumatic intracerebral hemorrhage and independent ambulation. The facility’s investigation documented that the cognitively intact resident came out of his/her room holding the aggressor resident’s arms and asked staff for help, but before staff could intervene, the aggressor resident hit the cognitively intact resident on the left side of the face, and the cognitively intact resident hit the aggressor resident in the mouth. Staff separated and redirected the residents, the nurse assessed both residents, placed them on 15‑minute checks, and notified the DON, ADON, physician, and responsible parties. The investigation report did not contain documentation that the allegation was reported to DHSS within two hours, and review of the DHSS complaint/facility self‑report database showed no record of a report for this incident. The administrator stated he/she investigated the 01/07/26 incident but believed it was the first physical altercation for the aggressor resident, and because there were no injuries, no suspicion of abuse, and interventions were implemented, he/she did not report the incident to DHSS, later acknowledging that, in light of the prior 12/18/25 incident, it should have been reported within two hours.