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F0609
D

Failure to Timely Report Alleged Abuse to State Authorities

Palm Desert, California Survey Completed on 04-24-2025

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 abuse to the California Department of Public Health (CDPH) within the required timeframe after a resident reported being roughly handled by a Physical Therapy Assistant (PTA), resulting in a skin tear. The resident, who was cognitively intact with a BIMS score of 15 and had a history of gait and mobility abnormalities, stated that the Director of Rehabilitation (DOR) was made aware of the incident when she requested a different PTA. The Occupational Therapist (OT) reported the allegation to the Physical Therapist (PT) and then to the DOR, believing the DOR would inform the Director of Nursing (DON). The PTA was aware of the allegation but was not suspended from duties following the report. The DON confirmed that she and the DOR checked on the resident after learning of the allegation but did not report the incident to CDPH, citing the absence of visible bruising as the reason. The resident's records did not document the abuse allegation, and facility policy required all reports of abuse to be reported to appropriate agencies and thoroughly investigated. The failure to report the allegation as required constituted a deficiency in the facility's abuse reporting procedures.

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