Failure to Report Suspected Resident-to-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse between two residents to the State Agency after being made aware of the incident. A grievance form documented that one resident reported another resident entering his room, bumping into objects, and startling him, causing him to spill his coffee. The reporting resident stated he tried to stop the other resident by grabbing his merry walker to prevent a fall due to spilled coffee. He reported that the other resident then grabbed his shirt, and he responded by grabbing the other resident’s shirt; the other resident then let go and slapped at his hands before leaving the room. The resident also reported feeling upset and threatened because he was not able to stand or defend himself. An incident document completed by the administrator recorded a similar account, including that the resident felt startled and that the other resident grabbed his shirt, with the reporting resident grabbing the other resident’s shirt tail and the other resident swatting at his hands with no contact. A restorative program note showed that the resident stopped a staff restorative aide in the hallway to report the incident, and that the nurse was notified immediately. Staff interviews confirmed that the incident was reported up the chain of command and that staff were instructed to provide closer supervision and keep the two residents apart. However, review of the facility’s self-report documents showed no incident reported to the State Agency within 48 hours of the event, and the administrator stated the interaction was not reported because there was no physical contact, resulting in a failure to report suspected abuse as required.
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