Failure to Timely Report and Document Abuse Investigations
Penalty
Summary
The facility failed to follow its abuse reporting policy for six out of fourteen residents sampled for abuse. In multiple instances, altercations and allegations of abuse between residents, as well as an incident involving a family member verbally abusing a resident, were either not reported to the California Department of Public Health (CDPH) as required or were reported late. The facility's policy mandates that results of abuse investigations be reported to the appropriate authorities, including CDPH, with documentation of dates and times. For one incident, a resident with vascular dementia threw a plate at another resident with dementia and chronic pain. Although an initial report was made, the follow-up investigation results were not sent to CDPH as required by policy. In another case, a resident with dementia, stroke, and dysphagia was involved in altercations with two other residents, one involving physical contact and another involving verbal aggression. Investigations were conducted for both incidents, but there was no documentation that the results were reported to CDPH. Additionally, a resident with dementia, mood disturbance, and anxiety was verbally abused by a family member during a visit. Staff overheard the family member using profanity and belittling the resident. The incident was not reported to CDPH within the required 24-hour timeframe, instead being reported 46 hours after the event. These failures to report and document abuse investigations as per facility policy had the potential to subject residents to mistreatment, neglect, or abuse.