Failure to Timely Report Alleged Abuse and Suspend Staff
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, who was admitted with diagnoses including dysphagia following a stroke and aphasia. The resident clearly verbalized to the charge nurse that a male therapist had touched her breast during a therapy session, identifying the individual and stating this was the second occurrence. The incident was not reported to the California Department of Public Health (CDPH) immediately, as required by facility policy, which mandates reporting within two hours of the allegation. The Certified Occupational Therapy Assistant (COTA) involved did not notify the Director of Rehab, the Registered Nurse Supervisor, or the Administrator about the allegation, despite being aware of the resident's complaint and discussing it with a family member. Interviews with facility staff, including the Director of Rehab, Registered Nurse Supervisor, Nurse Educator, Director of Nursing, and Administrator, confirmed that the COTA failed to follow the facility's abuse reporting policy. The Director of Rehab and Director of Nursing both stated that the COTA should have reported the allegation immediately and that the COTA should have been suspended pending investigation. The facility's policy, reviewed as part of the investigation, clearly outlines the requirement for immediate reporting of all alleged violations to the Administrator and state agency, but this procedure was not followed in this case.