Failure to Timely Report and Investigate Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment, dementia, Parkinson's disease, anxiety, and depression. A Certified Nursing Assistant (CNA) was observed by another CNA shaving the resident's pubic hair without medical reason or consent, using the resident's personal beard shaver. The resident appeared agitated during the incident, and the CNA who witnessed the event did not immediately report it. The incident was later observed by a Licensed Nurse (LN), who noticed the resident's pubic area was shaved in a sloppy manner and the skin was red. The LN submitted an incident report to Human Resources and informed the Director of Nursing (DON) the following day. Despite multiple staff members becoming aware of the incident, the facility did not report the suspected abuse to the California Department of Public Health (CDPH) within the required 2-hour timeframe from the time of awareness. The facility's policies and procedures did not specify the 2-hour reporting requirement, and staff interviews revealed a lack of clarity regarding the appropriate steps to take when abuse is suspected. The DON later acknowledged that staff are mandated reporters and should have reported the suspicion of abuse immediately or within 2 hours, but this was not reflected in the facility's written policies. Additionally, the facility failed to submit a summary of the investigation to CDPH within 5 business days, as required. The facility's policies did not include this 5-day reporting requirement, and the DON confirmed that a 5-day follow-up report was not provided. The lack of timely reporting and incomplete policy guidance contributed to the deficiency identified by surveyors.