Failure to Timely Report Allegations of Abuse Involving Two Residents
Penalty
Summary
The facility failed to report allegations of physical and verbal abuse involving two residents within the required 2-hour timeframe to the State Survey Agency and the state ombudsman, as mandated by the facility's abuse policy. The incidents involved a family member (FM) who was observed by a Certified Nursing Assistant (CNA) and another resident engaging in abusive behavior towards a resident, including pulling the resident's hair, pushing her head down, and yelling at her. The CNA reported the incident to the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS), who in turn informed the Director of Nursing (DON). However, no immediate report was made to the appropriate authorities as required by policy. Resident 1, who had a history of acute respiratory failure, anxiety disorder, and hypertension, was cognitively impaired and required significant assistance with daily activities. The abuse incident occurred while the resident was brushing her teeth and vomiting, during which the family member became angry, pulled her hair, and pushed her head down while yelling. The CNA intervened and later contacted the police when she did not receive a response from the facility administrator. The police arrived, and the resident was placed on monitoring for emotional distress. Interviews with staff confirmed that the incident was not reported to the Department of Public Health (CDPH) within the required timeframe, and the DON acknowledged forgetting to make the report. A second resident, who had a history of falls and fractures, also reported being verbally abused by the same family member, who yelled at her and told her to "shut up" multiple times. This resident expressed anxiety and distress related to the family member's presence. The facility's policy clearly states that all allegations of abuse, including those involving family members, must be reported immediately, but this protocol was not followed in these cases. The failure to report these incidents as required constituted a deficiency in the facility's abuse prevention and reporting practices.