Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to complete and provide a timely investigation report to the Department following an allegation of abuse involving a resident and a staff member. Specifically, after a resident reported not being treated with dignity and respect by a housekeeper, the administrator conducted an internal investigation but did not submit the required five-day follow-up investigation report to the Department. During an interview, the administrator stated that he was unaware of the requirement to send a follow-up report within five days after an abuse allegation, referencing guidance documents that did not indicate this obligation. A review of the facility's policy on abuse, neglect, exploitation, and misappropriation prevention confirmed that the facility is committed to investigating and reporting all allegations within federally required timeframes. However, the lack of a timely report in this instance meant that the Department did not receive necessary information to intervene or ensure protective actions for the resident involved and the other residents in the facility.
Plan Of Correction
Immediate Action Taken The Administrator reviewed the abuse investigation file involved. The alleged abuse was non-physical and was reported under California Welfare & Institutions Code 15630(a)(b)(1)(C). The code section calls for reporting to the local ombudsman or local enforcement agency. The initial report was made to the State Survey Agency, local ombudsman, and local law enforcement agency. Moving forward, results of investigation that fall under this State Law code section will be reported to the State Survey Agency under CFR Section 483.12(c)(4) within 5 working days. Action taken for other potentially affected residents The Administrator reviewed previously reported allegations, and all involved physical abuse in which both federal and state law requires reporting to the State Survey Agency, the local ombudsman, and local law enforcement agency. All initial reports were followed by a 5-day report to the State Survey Agency. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months.