Failure to Accurately and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate information was provided to the abuse coordinator, failure to report an allegation of resident-to-resident abuse to the abuse coordinator, and failure to timely report an allegation of verbal abuse for multiple residents. On one day, a staff member overheard a male resident (Resident B) threaten to kill a female resident (Resident C) if she entered his room. This staff member reported the threat to the DON, who instructed the staff member to inform Social Services; when informed, Social Services questioned what they were supposed to do about it. The Administrator later stated she was unaware of this threat. The following day, Resident C was ambulating down a hall when Resident B exited his room, grabbed her by the neck and shoulder, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, continuing to push her as she tried to get away. A staff member intervened and reported the incident to the DON, who said it would be reported to the Administrator. Another staff member witnessed Resident B grab Resident C at the top of her left shoulder and neck area, swivel her around, and shove her three times down the hallway. However, the incident report documented only that Resident C entered Resident B’s room and that Resident B, upset, placed his hands on her shoulders to turn her around and slightly pushed her from the back. The Administrator indicated she reported only what she had been told, had not yet obtained staff statements, and did not have the full story when she reported the incident. The deficiency also includes a separate resident-to-resident physical contact incident that was not fully reported to the abuse coordinator. A staff member reported that she had to separate Resident C from another resident (Resident D) after Resident D rammed her walker into Resident C’s legs. The Administrator later indicated that Resident D admitted to hitting Resident C in the leg with her walker because Resident C was in her personal space, and Resident D herself confirmed she pushed her walker into Resident C and hit her legs for the same reason. An incident report dated two days after the event indicated it was reported to the Administrator that Resident D made contact with Resident C’s legs with her rollator walker. The facility’s Abuse Prevention Program policy requires supervisors to immediately inform the Administrator or person in charge of all reports of incidents or allegations of potential mistreatment and requires the Administrator or designee to initiate an incident investigation upon learning of a report. The survey findings show that these requirements were not followed for the verbal threat, the physical altercation between Residents B and C, and the walker incident between Residents C and D.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.