Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident and a visitor, and did not report the results of the investigation to the State Survey Agency within the required five working days. The incident involved a resident with a history of hypertension and epilepsy, who was cognitively intact at the time, and who reported being physically assaulted by the sister of another resident. The visitor entered the room, accused staff of mistreatment, became agitated, and physically struck the resident, resulting in a scratch and discoloration on the resident's eyelid. This account was corroborated by a registered nurse who witnessed the aftermath and documented the injury. Despite the seriousness of the allegation and the visible injury, the facility administrator was unable to provide evidence that all staff who witnessed the incident were interviewed as part of the investigation. The administrator only provided a handwritten note from an interview with the alleged perpetrator, who denied the incident, and acknowledged that the investigation summary was not completed in a timely manner. Additionally, the administrator did not review or reconcile the nurse's documentation with the visitor's denial. The facility's policy required a written report of the results of all abuse investigations to be submitted to the California Department of Public Health Licensing and Certification within five working days of the reported allegation. However, the investigation summary was not completed or sent within this timeframe, and there was no evidence of a comprehensive investigation as required by policy.