F0607

D

Failure to Timely Report and Thoroughly Investigate Resident-to-Resident Altercation

Rocky Mount, North Carolina Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse policy and federal requirements for reporting and investigating alleged abuse following a resident‑to‑resident altercation. The facility’s Abuse and Neglect Prohibition policy, revised in 8/2023, stated that the center would investigate any alleged abuse, neglect, or misappropriation of resident property and report all allegations and substantiated occurrences to state/federal agencies and law enforcement. However, the policy did not specify that the Administrator must be notified immediately of alleged abuse, and it referenced reporting to the corporate office via “Risk Guide” without defining what that entailed. Surveyors found that after an altercation between Resident #1 and Resident #2, the facility did not report the incident to local law enforcement within 24 hours and did not initiate a timely, thorough investigation.

The incident occurred in the activity room on the evening of 2/14/26, when Resident #1, Resident #2, and Resident #3 were watching television. NA #1, seated at the nursing desk with a direct view into the activity room, heard Resident #1 yelling, “Stop. Leave me alone,” and heard Resident #3 say, “Hit her again.” As NA #1 entered the room, she saw Resident #2 hit Resident #1 in the face with his fist and then swing again, with Resident #1 raising her arm to block the second blow. NA #1 reported that she did not see Resident #1 provoke or hit Resident #2. NA #2 entered with NA #1 and later stated she saw both residents hitting each other but did not know who started it or where the blows landed. That night, Resident #1 had no visible marks, but within a couple of days she developed a black eye. NA #1 wrote a statement on 2/14/26 describing the incident and placed it under the Administrator’s door as instructed, and later added that before bed Resident #1 said Resident #2 had hit her in the eye.

Nurse #1, the 3–11 PM nurse on 2/14/26, reported that a NA told her the two residents were in an altercation and that Resident #1 had started hitting Resident #2, who eventually hit back. She assessed both residents and found no marks but did not notify the Administrator, acknowledging she knew she should have. The Scheduler, acting as Administrator on Duty that weekend, overheard NA #1 say that Resident #2 had hit Resident #1, confirmed with the nurse that the nurse was aware, and assessed Resident #1, finding no marks. Resident #1 told the Scheduler that a man had hit her and described a male resident; Resident #2 denied involvement. The Scheduler called the Administrator at home and reported that Resident #2 may have hit Resident #1 and that there were no injuries, and was told to have NA #1 write a statement and place it under the Administrator’s door. The Administrator later stated she understood this to be a verbal, non‑physical altercation and did not review NA #1’s statement until 2/17/26, did not speak with NA #1 until 3/4/26, and did not begin the investigation until 2/17/26.

By 2/16/26, the DON had not been informed of any alleged abuse, learning only that Resident #1 had darkening under her eye after the Administrator had already noticed it. On 2/17/26, the Administrator observed discoloration under Resident #1’s eye and obtained differing accounts from Resident #1, who first attributed it to a branch hitting her on the way to dialysis and then to a male resident who pushed her, pointing to her right anterior shoulder. The Administrator also interviewed Resident #2, who denied hitting anyone, and Resident #3, who stated that Resident #1 started hitting Resident #2 and that Resident #2 only pushed her away defensively. The facility’s initial allegation report to the state agency, submitted on 2/17/26, incorrectly listed the incident date as 2/17/26, later corrected in the five‑day investigation report to 2/14/26 with acknowledgment that the facility became aware on 2/17/26. Local law enforcement confirmed they did not receive a report of the alleged assault until 2/17/26 at 12:17 PM, indicating the facility did not notify law enforcement within 24 hours of the 2/14/26 altercation. The Administrator acknowledged that the incident was not reported to her as abuse initially, that the investigation was delayed because details were not clearly communicated and she had not read NA #1’s statement promptly, and that not all witnesses, including NA #1, were interviewed in a timely manner.

The facility’s investigative file contained conflicting witness accounts and documentation indicating that alleged abuse occurred on 2/14/26, while the initial report to the state agency cited 2/17/26 as the occurrence date. NA #1 reported that no one spoke with her about the incident after she submitted her statement until she was interviewed by the surveyor on 3/4/26, and the Administrator confirmed she did not interview NA #1 until that date. The DON reported that no one notified her of alleged abuse during the days immediately following the incident. These findings demonstrate that the facility failed to follow its own abuse policy and federal requirements by not ensuring immediate Administrator notification of alleged abuse, not reporting the alleged crime to law enforcement within 24 hours of the altercation, and not conducting a prompt and thorough investigation that included timely interviews of all witnesses.