Failure to Report Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state Department as required by regulation after one resident was pushed to the floor by another resident. Resident 1, admitted in January 2025 with dementia and documented moderate cognitive impairment on an MDS dated 3/3/25, was involved in a peer-to-peer altercation on 2/6/25. A progress note for Resident 1 dated 2/6/25 documented that, per Resident 3, Resident 2 entered the room and pushed Resident 1, causing Resident 1 to fall to the floor on his back and complain of left hip pain. The abuse coordinator was notified, but there was no documentation that the Department was notified of this abuse incident. Resident 2, admitted with bipolar disorder and severe cognitive impairment per an MDS, had a progress note dated 2/6/25 describing that Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor. An IDT note dated 2/7/25 further documented that a licensed nurse reported the 2/6/25 incident, and that the abuse coordinator, MD, responsible party, and Ombudsman were notified. Resident 3, admitted in January 2025 with multiple left rib fractures and moderate cognitive impairment, reported in a social services note dated 2/7/25 that she witnessed the peer-to-peer altercation in her room and felt uncomfortable. During an interview and record review on 3/27/25, the DON and Administrator confirmed the 2/6/25 altercation between Resident 1 and Resident 2 and acknowledged there was no documented evidence that the peer-to-peer abuse was reported to the Department, despite facility policies requiring investigation and reporting of abuse, including resident-to-resident abuse, within required federal timeframes.
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.