Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency within the required two hours after an incident involving two residents. Resident 9, who was admitted in 10/2024 with metabolic encephalopathy and atrial fibrillation and had a care plan dated 11/4/24 identifying cognitive loss affecting decision-making ability, was documented in a 2/7/26 facility incident report (completed on 2/15/26) as having placed a pillow over another resident’s face and thrown heat packs at that resident while the resident was sleeping. Staff interviews revealed that a RN case manager reported the incident to the Administrator, who stated the incident would be investigated but not reported to the State Agency, and the RN case manager believed administration handled the investigation. Another RN stated she reported the incident based on information from care staff, and that administration determined it was not reportable to the State Agency. The Administrator stated he was notified of the incident by care staff and did not report it to the State Agency because he did not believe it to be abuse, while acknowledging that all allegations of abuse must be reported to the State Agency within two hours of the allegation. This sequence of events, including the documented allegation of potentially abusive behavior by one resident toward another and the Administrator’s decision not to report the allegation despite staff notification and his awareness of reporting requirements, led to the deficiency for failure to timely report suspected abuse to the proper authorities.
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