Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy for two residents by not reporting an allegation of abuse to the appropriate authorities within the required timeframe. An incident occurred involving a verbal altercation between two residents, one of whom attempted to hit the other with a pillow. The altercation was witnessed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who intervened by moving one resident to a new room. However, the incident was not reported to the California Department of Public Health (CDPH), the state ombudsman, or local law enforcement within two hours as required by federal and facility policy. Resident 15, who was involved in the incident, had a history of severe cognitive impairment and required substantial assistance with daily activities. The resident's care plan was updated to reflect the risk for emotional and psychosocial distress following the altercation. Resident 241, the other party in the incident, also had severe cognitive impairment and a history of encephalopathy and psychosis. Documentation showed that the altercation was only recorded as a room change in the communication book, and no formal incident report was made at the time. Interviews with facility staff, including the DON, LVN, CNA, and Administrator, confirmed that the incident was not reported as required. The DON and Administrator both acknowledged that the event should have been reported within two hours, but the delay occurred because the incident was not brought to their attention until several days later during a meeting. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this procedure was not followed in this case.
Plan Of Correction
Immediate Corrective Action a. The new administrator faxed over the SOC-341 to the CDPH and Long-Term Care (LTC) Ombudsman, and reported to the local police district on 6/5/25, after being informed by the MDS Coordinator about the alleged altercation between residents 15 and 241. b. The final investigation report was faxed over to the ombudsman on 6/11/25 within 15 days from submitting the SOC-341. On 6/11/25, within 5 working days from submitting the Corrective Action for Others Affected, the progress notes for the residents contained in the residents' files were reviewed by the MAS, Coordinator, and analyzed. No other residents were found to be affected by the incident. Preventive Measures to Recurrence a. The previous DON resigned on 6/2/25 with immediate effect. b. LVN 3 was in-serviced over the phone by the new administrator in 2025 regarding the incident and documentation of allegations of abuse. c. The administrator in-serviced all staff on 6/6/25 regarding the prevention of abuse. Performance Monitoring and Solutions a. The MDS Coordinator will review, twice a month for the next 3 months starting 6/6/2025, 5 random progress notes of residents to verify documentation and allegations of abuse. The MDS Coordinator will report findings during the monthly QAPI meeting. b. The RN/DS Coordinator will report during the resident stand-up meeting at around 9:50 a.m., with progress notes of date achieved.