Failure to Timely Report Suspected Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an incident of suspected physical abuse between two residents to the proper authorities. Resident 6, admitted in 11/2024 with major depressive disorder, and Resident 7, admitted in 1/2026 with senile degeneration of the brain with anxiety and agitation, were involved in an altercation on 2/14/26 at 10:00 AM when Resident 7 struck Resident 6 with a reader stick after Resident 6 wandered into Resident 7’s room looking for personal items. A progress note entered on 2/14/26 at 12:28 PM documented that the Social Services Director (Staff 7) observed Resident 6 receiving assistance with a bandage to the knee, and upon inquiry, Resident 6 reported being hit by another resident after entering that resident’s room and approaching them. Staff 7 stated she completed an incident report regarding the event at approximately 12:00 PM on 2/14/26 and informed both the Facility Administrator (Staff 1) and the DNS (Staff 2) of the incident at that time. Despite this, the Facility Reported Incident (FRI) was not submitted until 2/14/26 at 6:27 PM, more than two hours after the facility became aware of the suspected abuse. On 3/10/26 at 12:26 PM, the DNS (Staff 2) acknowledged awareness of the incident and confirmed that allegations of potential abuse were required to be reported within two hours of occurrence, and further acknowledged that this incident was not reported within the required two-hour timeframe.
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.