F0609

D

Failure to Timely Report Resident-to-Resident Abuse Allegations to State Agency

Muncie, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report allegations of resident-to-resident abuse to the Administrator and to the Indiana Department of Health (IDOH) as required by policy and regulation. Resident B, who had dementia, major depressive disorder, anxiety, and severe cognitive impairment, had a care plan noting a history of threatening and physically aggressive behaviors such as shoving, hitting, and scratching. Progress notes documented that Resident B shoved another resident causing a fall and, on a later date, pushed another resident against a hallway wall, causing a head laceration and shoulder bruising that required ER transfer. Despite these documented aggressive incidents, the Administrator indicated that such altercations were not always reported to IDOH if they did not meet the facility’s internal guidance, and resident pushing could be considered abuse only depending on the circumstances.

Resident F, with vascular dementia, psychotic disorder with delusions, and anxiety disorder, was documented in a progress note as having fallen after being pushed by another resident, with the root cause identified as loss of balance after being pushed. An intervention of placing a stop sign on the doorway of a room she preferred to wander into was implemented. The DON and Administrator both acknowledged awareness of a resident-to-resident altercation involving Resident B and Resident F, but neither could recall who reported it or when, and the Administrator confirmed the incident was not reported to IDOH because it was determined not to meet the facility’s reporting guidance. The Administrator stated that staff typically reported abuse and resident-to-resident altercations to the charge nurse, who then reported to the Administrator, and that staff could also report directly to the Administrator if they chose.

Resident D, with severe dementia, schizophrenia, and anxiety disorder, was found sitting on the floor between the bed and wheelchair and reported that another resident had pushed him from the bed; later documentation indicated he reported being punched in the head and pushed from his wheelchair by another resident. CNA 19 reported seeing Resident B leaving Resident D’s room with fists balled and an angry expression, and then observed Resident B push another resident against a door jamb. CNA 22 and RN 4 found Resident D on the floor and documented that Resident D stated Resident B had shoved him to the floor. RN 4 did not report the allegation to the Administrator, assuming another nurse had done so. The Administrator later acknowledged being informed of an altercation involving Resident B and another resident and that Resident D alleged being pulled out of bed, but Resident D’s allegation was not included in the report to IDOH because he had no injuries, was not upset, and was known to embellish, and the facility believed the events were unrelated. These actions and inactions occurred despite a written facility policy requiring all abuse allegations, including resident-to-resident abuse, to be reported immediately to the Executive Director and to IDOH within two hours.