Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policies after an incident involving a certified nursing assistant (CNA) exposing her breasts in a resident's room. The incident was witnessed by another CNA, who reported that the CNA in question lifted her scrub top and exposed her breasts to the resident, who was awake at the time. The CNA later admitted to the exposure and stated it was a joke, referencing the resident's birthday. The resident involved was unable to make decisions and was rarely or never understood, as documented in their medical record and Minimum Data Set (MDS). Despite the incident, the facility did not report the alleged abuse to the appropriate authorities, including the state agency, ombudsman, law enforcement, or the resident's responsible party, within the required timeframes. The facility's policy required immediate reporting of abuse allegations, but there was no documented evidence of such reporting. Additionally, the facility did not initiate an abuse investigation, nor did it monitor the resident for clinical or psychosocial status following the incident. There was also no care plan developed in response to the alleged incident. Interviews with facility staff, including the Administrator and Director of Staff Development (DSD), revealed a lack of awareness and action regarding the incident. The Administrator considered the event a code of conduct issue rather than abuse, and the DSD described it as a rumor rather than a reportable event. No in-service training was provided to staff regarding the code of conduct or sexual abuse prevention after the incident was reported. These failures resulted in the facility not protecting the resident from potential abuse and not following required procedures for investigating and reporting such allegations.
Plan Of Correction
F 610 Corrective Action To Correct Deficiency: • On 5/24/25, upon being made aware of the allegation, CNA 10 was immediately suspended pending the outcome of an investigation and has since been terminated. • On 5/30/25, Resident 4 was assessed by the licensed nurse for any adverse clinical or psychosocial effects related to the incident, with none noted. • On 5/30/25, the facility initiated a formal investigation into the allegation of abuse. • On 5/30/25, Resident 4's physician and responsible party were notified of the incident and the investigation. • On 5/30/25, the incident was reported to the California Department of Public Health (CDPH), the long-term care ombudsman, and local law enforcement. • On 5/30/25, a care plan was initiated for Resident 4 to include interventions for psychosocial monitoring by licensed nurses and social services. Corrective Action To Correct Deficiency: • On 5/14/25, all of Resident 2's medications were received from the pharmacy and administered per physician orders. • On 5/14/25, Resident 2 was assessed by a licensed nurse for any adverse signs or symptoms related to the delayed medication administration. The resident's physician was notified, and no adverse effects were identified. Identify Any Other Residents Who May Have Been Affected By the Deficient Practice: • On 6/13/25, the DON initiated a full audit of all new admissions and readmissions from 5/12/25 to 6/13/25 to verify that all admission medication orders were received from the pharmacy and administered in a timely manner. No other residents were identified as being affected by a similar issue. Systemic Change To Prevent Recurrence: • On 6/11/25, licensed nursing staff were re-educated by the DON on the facility's Medication Reconciliation P&P for new admissions and readmissions. The training emphasized the process for verifying receipt of medications from the pharmacy within 24 hours of admission. • Effective 6/12/25, a new verification process was implemented. The nursing unit manager or designee on each shift is now required to use a "New Admission/Readmission Pharmacy Checklist" to verify that all new medication orders have been faxed to the