Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Survey Agency within the required two-hour timeframe following a resident-to-resident physical altercation that resulted in injury. Facility policy on Abuse, Neglect and Exploitation, dated 4/8/24, defined abuse and outlined general reporting expectations but did not specify that allegations of abuse must be reported to the State Survey Agency immediately, but not later than two hours after the allegation is made, as required by federal regulations. The facility’s Abuse Prevention Plan stated that anyone could report suspected abuse to the abuse agency hotline and that the licensed nurse should respond to the resident’s needs and notify the Administrator and DON, but again did not include the mandated timeframes. The incident involved two residents. One resident, with no cognitive impairment and diagnoses including anxiety disorder and depression, had a care plan problem related to poor impulse control, hitting another resident, and noncompliance with smoking rules. Nursing documentation on the evening of the incident recorded that this resident struck another resident in the eye after an altercation over a cigarette in the smoking area. In a subsequent interview, this resident stated that the other resident drooled on them and tried to take their cigarette, and that they pulled the other resident to the ground and punched them in the nose. The resident was placed on 15-minute checks for behaviors. The other resident involved had severe cognitive impairment and diagnoses including hypertension, stroke, seizure disorder, anxiety, and depression. Nursing notes documented that this resident walked up on another resident trying to take a cigarette, drooled on the other resident, and was then hit in the eye, resulting in a black and purple discoloration under the left eye orbit. The ADON was notified by the charge nurse about the altercation and was told the injured resident had redness under the left eye, but did not review the notes or see the residents until several days later. The Administrator read the nurse’s notes describing the black eye and chose to wait to see the injury before reporting to the Department of Health and Senior Services. The incident occurred on 2/28/26 but was not reported to DHSS until 3/2/26, exceeding the required two-hour reporting timeframe.
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