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F0609
D

Failure to Timely Report Alleged Physical Abuse

Montebello, California Survey Completed on 04-23-2025

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 report an allegation of physical abuse involving a resident who reported being punched on the leg by an unnamed nurse. The resident, who had a history of infection of amputation stumps, anxiety disorder, and transient cerebral ischemic attack, was cognitively intact and dependent on staff for several activities of daily living. On the date of the incident, the resident informed a Licensed Vocational Nurse (LVN) that a nurse had punched him. The LVN documented the allegation in a Change of Condition (COC) form but did not notify the California Department of Public Health (CDPH), the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's policy and procedure. The Interim Director of Nursing (IDON) later discovered the abuse allegation during a review of nursing notes two days after the incident and subsequently reported it to the appropriate authorities. The facility's policy clearly states that any suspicion or allegation of abuse must be reported immediately to the administrator and to state agencies, the Ombudsman, and law enforcement within two hours. However, this protocol was not followed, resulting in a delay in reporting and investigation of the abuse allegation.

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