Late Reporting of Resident-to-Resident Altercation to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident altercation to the State Survey Agency (SSA) within the required two-hour timeframe for alleged abuse. On 2/6/26 at 10:47 a.m., two residents engaged in a verbal and physical altercation. Staff noted the residents speaking in elevated tones and attempted to de-escalate the situation, but one resident grabbed the other while four staff members were present. Paramedics and police were notified; both residents refused medical care from paramedics. Police arrived at 11:28 a.m. and transferred one resident to a general acute hospital at 12:18 p.m. for further evaluation. The facility’s initial report to the SSA, sent by fax, was transmitted at 4:05 p.m. the same day, more than two hours after the incident. One resident involved had diagnoses including dementia, anxiety disorder, and schizoaffective disorder, with an MDS indicating severely impaired cognitive skills and a need for varying levels of assistance with ADLs such as bathing, dressing, personal hygiene, and footwear, while remaining independent with eating, oral hygiene, and toileting hygiene. The other resident had diagnoses including legal blindness, depression, and generalized muscle weakness, with an MDS indicating intact cognition, need for set-up assistance with toileting hygiene, bathing, lower body dressing, footwear, and personal hygiene, and independence with eating, oral hygiene, and upper body dressing. During an interview and record review, the administrator acknowledged that allegations of abuse should be reported to the SSA within two hours and confirmed the 4:05 p.m. reporting time. The administrator stated the belief that, because one resident had dementia and there was no serious bodily injury, the incident could be reported within 24 hours, despite the facility’s abuse policy specifying that alleged violations involving abuse must be reported immediately, but not later than two hours, if they involve abuse or result in serious bodily injury.
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