F0609

D

Failure to Report Resident-to-Resident Abuse Allegations to Required Agencies

Tunkhannock, Pennsylvania Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and report alleged resident-to-resident abuse to required external agencies within mandated timeframes. The facility’s Abuse, Neglect, and Exploitation policy, last reviewed on January 23, 2026, requires that all alleged violations that could indicate mistreatment, exploitation, neglect, or abuse be reported to the administrator, state agency, adult protective services, and other required agencies. The policy specifies that allegations involving abuse or serious bodily injury must be reported immediately, but no later than two hours after the allegation is made, and all other qualifying events within 24 hours. Despite this policy, the facility did not report two separate incidents involving interactions between two residents that met the definition of alleged resident-to-resident abuse.

Resident 1 was cognitively intact with a BIMS score of 15 and had a care plan for behavioral concerns, including verbal agitation and aggression toward staff and the roommate and the roommate’s family, with interventions to avoid situations or people that upset him. Resident 2 had diagnoses including diabetes and intellectual disabilities, was rarely or never understood per the MDS, and was documented as moderately impaired in cognitive skills for daily decision making. On one occasion, investigative documentation and staff interview revealed that Resident 1 wheeled Resident 2 in her wheelchair into Resident 2’s room, shut the door, and made a statement to the effect that if Resident 2 acted up, she would stay in the room. Video review confirmed that Resident 1 wheeled Resident 2 into her room and shut the door before returning to his own room, and staff entered Resident 2’s room shortly afterward and remained with her for several minutes.

On a separate date, investigative documentation and a progress note indicated that Resident 1 was observed ramming or intentionally striking Resident 2’s wheelchair multiple times with his own wheelchair. These incidents were investigated internally by the Nursing Home Administrator, who interviewed Resident 1 about the events. Resident 1 reported that he did not believe he harmed Resident 2 and that he sometimes assisted her to her room when she appeared upset. During an interview, the Nursing Home Administrator confirmed that he investigated the allegations of resident-to-resident abuse between these two residents but did not report the incidents to the state agency or adult protective services. The facility therefore failed to identify these events as allegations of resident-to-resident abuse that must be reported to required external agencies within required timeframes, regardless of the investigation outcome.