Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to ensure that an allegation of physical abuse was reported to the California Department of Public Health (CDPH), local law enforcement, and the Ombudsman within two hours, as required. The incident involved a resident with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, and hypertension, who was cognitively impaired and dependent on staff for daily activities. This resident reported that another male resident entered her room and touched her leg and gown, which made her feel uncomfortable and fearful. The event was initially reported by a Certified Nurse Assistant (CNA) to the charge nurse around 7:30 PM, and the resident's responsible party later called the facility to report the same allegation. Despite the facility's policy requiring immediate reporting of abuse allegations, the Licensed Vocational Nurse (LVN) did not report the incident at the time it was disclosed, citing being occupied with medication administration. The LVN also did not instruct another nurse to report the allegation to the administrator. The administrator was eventually informed of the incident around 9:30 PM, and the abuse allegation was officially reported at 11:11 PM, nearly four hours after the initial disclosure. The Director of Nursing (DON) confirmed that the reporting should have occurred within two hours of the resident's claim, and the delay was acknowledged during interviews and record reviews. The second resident involved, who also had cognitive impairment and mental health diagnoses, was identified as the individual who entered the female resident's room. Staff interventions included 1:1 monitoring and notification of the physician, but the primary deficiency was the failure to report the abuse allegation within the required timeframe. The facility's policy, reviewed with the DON, clearly stated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the appropriate authorities.