Failure to Timely Report Resident-to-Resident Physical Altercation as Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe following a physical altercation between two residents. The facility’s Abuse and Neglect policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately to the Administrator and appropriate agencies within prescribed time frames, and defined abuse to include certain resident-to-resident altercations and physical abuse such as hitting and punching. Despite this policy, review of the DHSS reporting system showed no documentation that the facility submitted a report regarding the physical altercation between the two residents. Resident #1 had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke. Nursing notes documented that a verbal disagreement between Resident #1 and his/her roommate, Resident #2, escalated, requiring the nurse to physically separate them and move Resident #1 to the hallway; however, Resident #1 repeatedly returned to the room, and staff were later called back for a “fight.” LPN A found Resident #2 standing over Resident #1, yelling, and both residents stated they had hit each other. Resident #1 later reported being hit and hitting back, and Resident #2 reported being hit in the chest. Resident #1 was kept near the nurse’s station for safety and expressed a desire to go to the hospital and voiced suicidal ideation. Resident #2’s record contained no documentation of the altercation. The DON stated she expected the Abuse and Neglect policy, including timely state reporting, to be followed and did not know why reporting did not occur. The Administrator stated she was initially told there was no physical contact and therefore did not believe the incident needed to be reported to DHSS.
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