Failure to Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident-to-resident altercation to the California Department of Public Health (CDPH) as required. Two residents were involved in an incident where one resident, who had moderate cognitive impairment and a diagnosis of dementia, allegedly threw a metal object at another resident, resulting in a skin tear to the hand. The injured resident was alert, oriented, and able to answer questions appropriately at the time of the incident. The incident was reported to the police and the Ombudsman, but not to CDPH. Facility staff, including a CNA and LVN, described the process for handling resident-to-resident altercations, which included separating the residents, assessing for injuries, notifying physicians and resident representatives, and reporting to outside agencies. However, both the Administrator and the Director of Nursing stated that, based on their interpretation of state guidance (AB-1417 and AFL 24-09), incidents involving a resident with dementia and no serious bodily injury only required reporting to the Ombudsman and local law enforcement, not to CDPH. This interpretation was reflected in the facility's policies and procedures, which referenced following state law and reporting requirements. Despite these actions, federal regulations (42 CFR 483.12) require that all alleged violations involving abuse be reported to the State Survey Agency, regardless of the cognitive status of the residents involved. The facility's failure to report the incident to CDPH meant that the alleged violation involving resident-to-resident abuse was not reported within the required timeframe, and this had the potential for additional allegations of abuse to go unreported.