Failure to Timely Report Resident-to-Resident Abuse and Investigation Results
Penalty
Summary
The facility failed to timely report an incident of resident-to-resident abuse to the State Agency and failed to submit the required investigation report within the regulatory timeframe. An untitled facility document showed that an incident of abuse between Resident 1 and Resident 2 occurred on 2/28/26 at 12:45 PM, and the Administrator was notified that same day at 1:15 PM. Resident 1 had unspecified dementia, weight loss, unsteadiness on feet, and type 2 diabetes mellitus, while Resident 2 had chronic obstructive pulmonary disease, pneumonia, bladder dysfunction, and heart failure. Despite the facility’s abuse prevention plan policy stating that alleged violations of abuse or neglect are to be reported to the Administrator and the State Agency immediately, the State Agency was not notified until 3/2/26 at 1:00 PM. Record review and interviews confirmed that the Director of Nursing was notified by telephone on 2/28/26 that an incident of abuse had occurred between the two residents and that the Director of Nursing then notified the Administrator by telephone the same day. The Administrator stated that the incident was reviewed on the next working day, 3/2/26, and only then reported to the State Agency, which was beyond the 24-hour requirement in regulation and facility policy. The same untitled document and the Administrator’s interview further confirmed that the results of the investigation were submitted to the State Agency on 3/6/26, which exceeded the required 5 working days for submission of the investigative report.
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.