Failure to Timely Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to follow its abuse reporting policy for two residents involved in a physical altercation. One resident with hemiplegia and hemiparesis and another resident with schizophrenia, schizoaffective disorder, and major depressive disorder, who had intact cognition with a BIMS score of 15, were roommates at the time of the incident. An initial abuse reportable incident was submitted alleging that the cognitively intact resident made physical contact with the other resident, who then retaliated by striking with a reacher while seated in a wheelchair. Social service notes documented that the aggressive resident was sent to the hospital for psychiatric evaluation due to aggression toward the roommate and difficulty with redirection, and census records showed that this resident later returned to the facility on the same floor but a different room. The facility’s Abuse Prevention Program required that abuse allegations involving one resident upon another be reported to the state agency and that a final written investigation report, including specified investigative details, be forwarded within five working days of the incident. The administrator/abuse coordinator acknowledged that the final report, which concluded that the aggressive resident did hit the roommate and that the act met the definition of physical abuse, was not submitted within the required timeframe. The final report, including reference to a police report documenting simple battery, was sent more than two weeks after the incident because the administrator forgot to send it and did not follow the policy requiring submission of the initial and final reports within five working days.
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