Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH) as required by policy and regulation. On the evening of March 28, 2025, a resident (who is deaf and nonspeaking, with severe cognitive impairment) was allegedly struck on the back of the head by another resident with schizoaffective disorder and moderate cognitive impairment. The incident was witnessed by a third resident, who reported it to the nurse's station, where both an LVN and an RN were present. Documentation in the medical record confirmed the incident and subsequent monitoring of the resident, but there was no evidence that the required report to CDPH or the Ombudsman was made at that time. Interviews with staff revealed that the LVN informed the RN of the incident and relied on the RN for direction, but no further action was taken to report the abuse within the mandated timeframe. The RN assumed the LVN would handle the reporting, but did not follow up to ensure it was completed. The Director of Nursing was not informed of the incident until the following morning, well beyond the two-hour reporting window. Facility policy clearly states that all allegations of abuse must be reported to the appropriate authorities immediately, and within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the alleged abuse in a timely manner was confirmed through record review, staff interviews, and review of facility policy. The delay in reporting had the potential to place the affected resident at continued risk of abuse and negatively impact her emotional and psychosocial well-being, as noted in the findings.