Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when one resident pushed another resident to the floor, and the incident was not reported to the state agency as required. Resident 1, admitted in January 2025 with dementia and documented as having moderate cognitive impairment on an MDS dated 3/3/25, was pushed by Resident 2 on 2/6/25. A progress note for Resident 1 on that date documented that another resident (Resident 3) reported Resident 1 had been pushed by Resident 2, that Resident 1 was found lying on his back on the floor, and that when Resident 1 began walking he verbalized left hip pain. The abuse coordinator was notified. Resident 2’s record showed an admission diagnosis of bipolar disorder and severe cognitive impairment on an MDS, and a change-of-condition note dated 2/6/25 documented that Resident 3 reported Resident 2 pushed Resident 1 when he entered their shared room, causing Resident 1 to fall to the floor on his back. Staff responded after hearing loud voices and found Resident 2 standing in the room and Resident 1 lying on his back on the floor; both residents were unable to explain what happened. An IDT note for Resident 2 dated 2/7/25 reiterated that, per the licensed nurse, Resident 3 reported Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor on his back, and documented that the abuse coordinator, physician, responsible party, and Ombudsman were notified. Resident 3’s record showed admission in January 2025 with multiple left rib fractures and moderate cognitive impairment on an MDS dated 2/17/25, and a social services note dated 2/7/25 indicated Resident 3 reported witnessing a peer-to-peer altercation in her room. During an interview and concurrent record review on 3/27/25 with the DON and Administrator, they confirmed that a peer-to-peer altercation occurred between Resident 1 and Resident 2 on 2/6/25 and acknowledged there was no documented evidence that this peer-to-peer abuse incident was reported to the Department. This failure occurred despite facility policies stating that abuse of any kind, including resident-to-resident abuse, is prohibited and that allegations of abuse and neglect must be investigated and reported within required federal timeframes.
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