Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of suspected abuse within 24 hours as required by its policy and staff-stated procedures. During interviews, staff members B and C stated that incidents must be reported within 24 hours and that investigations begin as soon as a reportable event is known, with annual abuse training and additional in-services on abuse and reporting timelines. Staff member A stated that the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents, and confirmed that the time frames for reporting to the State Survey Agency are 2 hours for incidents involving serious bodily injury and 24 hours for incidents without serious bodily injury, with investigation findings due within 5 days. Record review showed that an incident of resident-to-resident abuse involving an altercation between residents #8 and #10, which occurred on 8/16/25, was not reported to the State Survey Agency until 8/18/25, exceeding the 24-hour reporting requirement. Review of the facility’s policy titled “Mandatory Reporting for Montana Nursing Facilities” confirmed that resident-to-resident abuse must be reported within 24 hours of discovery, that there is a 2-hour reporting requirement for crimes resulting in serious bodily injury, and that investigation results must be sent to the state agency within 5 working days of receipt of the abuse report. Despite these established policies and staff awareness of the required timelines, the facility did not submit the abuse incident involving residents #8 and #10 within the mandated 24-hour period from the date of the incident.
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