Failure to Ensure Successful and Timely Reporting of Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Investigation and Reporting policy by not ensuring that an alleged physical altercation between two residents was successfully reported to the state licensing/certification agency and a local agency. One resident, with diagnoses including osteoarthritis and myocardial infarction, reported that another resident, with diagnoses including Alzheimer’s disease, schizophrenia, and bipolar disorder, slapped her on the left shoulder and yelled at her to move out. An incident report dated 2/24/26 documented this allegation. The facility’s policy required that all alleged violations involving abuse be promptly reported to specified agencies, including the state licensing/certification agency, the Ombudsman, and law enforcement, within defined time frames depending on the nature and severity of the alleged abuse. Record review showed that on 2/25/26 the facility attempted to fax the Elder Abuse Report Form (SOC 341) and cover sheet to the state agency district manager and a local agency, but both fax transmissions failed, with the communication result reports indicating “Page Not Sent” and “No answer.” The Director of Nursing acknowledged that the fax did not go through and that the communication result reports showed an error. The Administrator confirmed that both faxes resulted in failed communication and that the error was not identified at the time, and the Unit Manager stated that someone must have placed the fax communication result report in the Administrator’s box without checking whether the fax had gone through. As a result, the licensing agency did not become aware of the physical altercation until after receiving the facility’s Abuse Investigation Summary on 2/27/26, contrary to the facility’s policy requiring immediate reporting within specified time frames.
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