Failure to Timely Report Allegation of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson’s disease, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder, was admitted on an unspecified date and had an MDS dated 12/02/25 showing severe cognitive impairment. On 12/12/25, staff heard the resident yelling and found him lying on the floor with his head and torso outside the room and his legs inside, while his roommate was present in the room, standing over him and yelling. A full body assessment documented a small amount of bleeding and a raised area on the scalp consistent with possible head impact, and the resident appeared fearful and confused during the assessment. EMS was contacted and the resident was transported to the hospital for evaluation of a head injury. Progress notes and the Facility Reported Incident (FRI) show that the event was identified as an allegation of physical abuse between the two residents, with staff reporting that the roommate was swearing loudly and threatening that if touched again, the resident would not be able to stand back up. The Administrator and DON confirmed they were notified of the incident on the night it occurred and were told that the roommate had stated he smacked the resident, causing him to fall. The Administrator confirmed that, during his interview, the roommate admitted to smacking the resident, but the Administrator reported the incident to the state the next day because he initially believed it was an unwitnessed fall, despite knowing of the admission of having smacked the resident. The facility’s Abuse, Neglect, and Exploitation policy required that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after the allegation is made. The delay in reporting this allegation of abuse constituted the cited deficiency.
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