Other·May 1, 2025

REGULATION VIOLATION(S) 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an incident of alleged resident-to-resident abuse to the Department of Public Health within 24 hours, when the Administrator did not report an alleged resident-to-resident altercation between Resident 1 and two of two sampled residents (Resident 2 & Resident 3). The Administrator did not report the alleged altercation per the facility's policy and procedure, after he was notified by the Ombudsman about Resident 1, who had allegedly entered Resident 2's room and struck her with a wheelchair leg rest and entered Resident 3's room and struck her with a plastic pack of wipes. This could decrease the Department's ability to ensure a complete investigation was done and interventions were started to protect the residents involved and other residents so there was no reoccurrence of abusive behavior. During an interview with the Administrator on 8/3/22 at 2:15 p.m., the Administrator stated the Ombudsman came into the facility early 7/2022, and she mentioned to him Resident 1 being abusive to Resident 2 and Resident 3 per her conversation with Resident 2 and Resident 3. The Administrator stated he interviewed both Resident 2 and Resident 3 while the Ombudsman was present. The Administrator stated he had never heard anything about Resident 1 going into Resident 2's and Resident 3's room and being physically aggressive. The Administrator stated none of the staff had seen anything, and Resident 2 and Resident 3 did not report the incidents to staff. The Administrator stated Resident 1 was cognitively impaired and could not be interviewed. The Administrator stated Resident 2 stated Resident 1 had taken a wheelchair footrest stored on the footboard of her bed and was hitting/beating Resident 2 with the footrest. The Administrator stated Resident 2 could not remember details of when the event occurred; she then said months earlier and stated Resident 1's name. The Administrator stated Resident 2 did not tell her Physician about Resident 1 hitting her leg with a wheelchair footrest. The Administrator stated he called Resident 2's Physician on 7/7/22, soon after talking to both Resident 2 and Resident 3 with the Ombudsman. The Administrator stated Resident 2's Physician stated Resident 2 could confabulate. The Administrator stated Resident 2's Physician stated to him, she could not see Resident 1 hitting Resident 2 with a wheelchair footrest; she would have seen bruising, but Resident 2's Physician did not see any bruising on Resident 2's legs. The Administrator stated Resident 3 had not reported the allegation of abuse to staff and had no details about the incident. The Administrator stated Resident 3 explained Resident 1 picked up something and placed it on Resident 3's face. The Administrator stated he did not think he needed to file a SOC341 (Report of Suspected Dependent Adult/Elder Abuse form) because there was no evidence of Resident 1 physically abusing Resident 2 and Resident 3. The Administrator stated he did not send the Ombudsman a report about his outcomes to the investigations because the Ombudsman was with him during the interviews and no details were given. The Administrator stated he did the investigations fast and concluded the incidences did not happen; nothing to report. The Administrator stated he talked to floor staff (Nurses/Certified Nursing Assistants), the Director of Nursing, Activities, and Social Services. The Administrator stated there were no concerns from staff regarding Resident 1 being abusive toward residents and no other residents reported issues with Resident 1. During an observation on 8/3/22 at 3:15 p.m., Resident 1 was in her bed sound asleep. A review of Resident 1's Quarterly MDS (Minimum Data Set, a clinical assessment process that provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 6/8/22, indicated Resident 1 had a BIMS (Brief Interview of Mental Status) of three (severely cognitively impaired). During an interview on 8/3/22 at 5:20 p.m., the Administrator stated the Ombudsman had gone with him when he started his investigation regarding allegations of Resident 1 being physically abusive toward Resident 2 and Resident 3. The Administrator stated Resident 2 and Resident 3 could not recall details of their allegations of Resident 1 physically hitting them. The Administrator stated he had not sent his, "Allegation Follow-up," report to the Ombudsman's office and/or he did not fill out a SOC341 and send the form to the proper authorities because he did not feel it was necessary. The Administrator stated he did not suspect abuse. During an observation and interview on 8/3/22 at 3:35 p.m., Resident 4 was up in her wheelchair across from the nurse's station. Resident 4 stated no resident has ever tried to hit her. During an interview on 8/12/22 at 10 a.m., Resident 2 stated Resident 1 used to be her roommate and hit her several times in the past. Resident 2 stated she has not seen Resident 1 in a while. Resident 2 stated Resident 1 hit her with the television wall mount arm by swinging the television wall mount arm at Resident 2. Resident 2 stated Resident 1 would ambulate, "all over the place." Resident 2 stated three wheelchair footrests were dangling at the end of Resident 2's bed, and Resident 1 beat her with one of the wheelchair footrests. Resident 2 stated Resident 1 broke her earbuds (a very small headphone, worn inside the ear) by yanking them off her face. Resident 2 stated Resident 1 thought Resident 2's belongings were hers. Resident 2 stated her legs were very swollen so Resident 2 could not see any bruising until the swelling went down and saw her left leg was bruised from Resident 1 hitting her with a wheelchair footrest. Resident 2 was rambling, agitated and details did not make sense. Resident 2 could not say when the allegations of abuse took place, who she reported incidences to, or even if she reported the incidences. Resident 2 stated her Physician examined her leg. The facility policy/procedure titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting & Investigating, revised 4/2021, indicated: "Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman, c. The resident's responsible party, d. Adult protective services (where state law provides jurisdiction in long-term care), e. Law enforcement officials, f. The resident's attending physician, and g. The facility medical director. 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury: or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal /written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone ..." Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. The violation of the regulation had a direct relationship to the health, safety or security of residents.