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F0609
E

Failure to Timely Report Abuse Allegation and Staff Unawareness of Reporting Requirements

Santa Rosa, California Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy for one resident when an abuse allegation was made. The incident occurred when a resident reported an allegation of abuse, but the facility did not report the allegation to the State, Ombudsman, and law enforcement within the required two-hour timeframe. Instead, the report was made the following day, exceeding the policy's definition of 'immediately,' which is within two hours for abuse allegations. Interviews with six facility staff members, including licensed nurses, the Social Services Assistant, the Director of Staff Development, the administrator, and the Director of Nursing, revealed a consistent misunderstanding of the required reporting timeframe. Most staff believed that abuse allegations without injury should be reported within 24 hours, and only those with injury within two hours. The Social Services Assistant specifically stated she did not know the required timeframe for reporting abuse allegations. A review of the facility's policy and procedure confirmed that any suspicion of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within two hours for abuse allegations. The failure to report the abuse allegation within this timeframe, as well as the lack of staff knowledge regarding the correct reporting protocol, led to the deficiency.

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