Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the required timeframe for two residents. In the first instance, a Certified Nursing Assistant (CNA) observed another CNA allegedly pushing a resident roughly onto her bed. The incident occurred in the early morning, but the witnessing CNA did not report the event to facility staff until nearly 22 hours later, despite being aware of the requirement to report such incidents within two hours. The resident involved had severe cognitive impairment, a history of falls, and required assistance with personal care. The facility's internal investigation was not initiated until the incident was reported, and the final report was not sent to CDPH until several days after the event. In the second case, a family member of another resident contacted the local police department on two separate occasions, alleging that the resident was being abused by facility staff. The police conducted welfare checks and informed facility staff of the abuse allegations. Despite this, the facility did not report the allegations to CDPH or the Ombudsman as required by both federal regulations and the facility's own policies. The resident in question was severely cognitively impaired, frail, and on hospice care, with a history of skin breakdown and bruising. Staff were aware of the family member's repeated concerns and the police visits but did not escalate the allegations to facility management or external authorities. Interviews with facility staff, including CNAs, LVNs, the Director of Nursing, and the Administrator, confirmed that all were aware of the mandated reporting requirements, which stipulate that all allegations of abuse must be reported within two hours. However, in both cases, staff either delayed reporting or failed to report the allegations altogether, resulting in untimely investigations and notifications to the appropriate authorities. Facility policies and in-service training documents reviewed during the survey reiterated the immediate reporting requirements, which were not followed in these instances.