Failure to Timely Report Alleged Abuse to Required Authorities
Penalty
Summary
The facility failed to ensure that multiple allegations of abuse involving residents with specific diagnoses were reported to the required authorities in accordance with federal regulations. In one instance, a resident reported being abused while at an outside medical facility. The Therapeutic Activities Staff (TAS) was informed of the allegation and relayed it to the Social Worker (SW), but neither the TAS nor the SW reported the allegation to local law enforcement, the Ombudsman, the state survey agency (CDPH), or the facility Administrator within the required two-hour timeframe. Interviews with the SW, Supervising Registered Nurse (SRN), and Nurse Practitioner (NP) revealed that they did not consider the report credible enough to warrant immediate reporting, citing the resident's medical condition as a factor. The Administrator confirmed he was not notified of the allegation within the required timeframe and was unable to provide documentation of timely notification. In a separate incident, another resident was witnessed by staff abusing a fellow resident in a common area. The Registered Nurse (RN) reported the incident to the Ombudsman and local law enforcement but did not notify CDPH, following facility training that such incidents did not require reporting to the state survey agency if the abuse was caused by a resident and did not result in serious bodily injury. The facility's policy and procedure, as well as staff interviews, confirmed that the protocol did not align with federal requirements for reporting all allegations of abuse to the state survey agency, regardless of the perpetrator or injury severity. These failures resulted in delays in the investigation process by local law enforcement, the Ombudsman, and the state survey agency. The facility's census at the time was 141, and the lack of timely and comprehensive reporting of abuse allegations was confirmed through interviews, record reviews, and examination of facility policies and staff training materials.
Plan Of Correction
F609 a) 1. Resident 1 was assessed on April 10, 2025, with no injuries or emotional distress noted, including no signs of [R]. Resident was assessed and placed on close monitoring following [R] at the outside facility on March 4, 2025. Resident had no complaints, including no complaints of headache, nausea, vomiting, or body soreness. No skin issues were noted. IDT for the alleged incident that occurred at the outside facility scheduled for April 11, 2025. Resident's [R] at outside facility were postponed until investigation conducted determined it was safe to proceed. SOC341 was filed on April 10, 2025, and CDPH, LTC Ombudsman, and CHP notified. The Therapeutic Activities Staff, Social Worker, Supervising Registered Nurse, Director of Nursing, Staff Nurse Instructor, Nurse Practitioner, and Administrator were all in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. 2. Resident 1 was immediately assessed after the alleged incident on April 4, 2025, with no injury noted. Residents 1 and 2 were immediately separated to ensure the safety of Resident 1. During immediate interviews conducted separately by Nursing and Social Work staff, Resident 1 denied any inappropriate physical contact between Resident 1 and Resident 2. Resident 1 denied any emotional distress related to the alleged event. Resident 1 was placed on close monitoring for emotional distress following the incident; none was noted. Resident 2 was placed on 1:1 nursing observation on April 4, 2025, to be in place indefinitely until IDT determines it is clinically appropriate and safe to taper. Resident 2 was assessed by psychiatric NP, and a medication change was ordered by [R] primary care physician, with daily monitoring for inappropriate behavior. Resident 1 and Resident 2 will continue to be housed in separate wings of the unit, with meals held in different dining rooms, to minimize potential contact. IDT meetings were held for both residents, and care plans updated at that time. SOC341 was sent to CDPH on April 10, 2025. RN, SRN, and Administrator were in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for all elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. b) The facility has determined that all residents have the potential to be affected. All incident reports and resident records from the past calendar year were audited for allegations of [R] by the Standards and Compliance manager and designee on April 10 and April 11, 2025. Through record review and audit, the facility has not found any other residents affected by the alleged deficient practice. c) An updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health, was created and distributed throughout the facility, including by email, on April 10, 2025. Unit television screens were updated to include slides of the updated mandated reporting tree on April 10, 2025. The SNF Administrator in-serviced all department supervisors on April 10, 2025, and they in turn will in-service all facility staff within their respective departments on F609, facility policy, "Elder Abuse Prevention and Response," the updated mandated reporting tree, updated instructions for whom to notify in-house for any suspicion of abuse or neglect, with emphasis on notifying the facility's Abuse Coordinator and the Standards & Compliance Manager, and the SOC341 form. In-services will be complete by May 11, 2025. d) Starting April 10, 2025, the Standards & Compliance Manager and/or designee began auditing all incident reports weekly to ensure any events that could be perceived as re-reported to all required entities and agencies. In addition, in-service trainings on elder abuse prevention, response, and mandated reporter requirements will be provided annually to all staff by the Director of Staff Development and as needed. In addition, Standards & Compliance staff will conduct quarterly random reviews and interviews with facility staff throughout the facility to ensure staff understanding of the mandated reporter requirements. All findings will be reported to the SNF Administrator and facility QAPI committee for monthly review and continuous quality improvement until the QAPI committee deems compliance has been sustained. Administration will revisit and modify the plan of correction as needed. e) Corrective action will be in place on or before May 11, 2025.