Failure to Timely Report Suspected Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, as well as the results of investigations, to the appropriate authorities for four out of ten sampled residents. According to the facility's Abuse Prohibition Policy, allegations of abuse must be reported within two hours of the allegation being made. However, in multiple instances, this policy was not followed, resulting in delayed notifications to the California Department of Public Health (CDPH) Licensing & Certification (L&C) Program and local law enforcement. One incident involved a resident who alleged physical abuse by a mental health worker (MHW), stating that the staff member choked and slammed the resident's face into the ground. The resident was observed with visible injuries, including bruising and scratches. The DON acknowledged the incident and confirmed that the reporting was not completed within the required timeframe. In another case, a resident reported verbal abuse by a staff member who mocked his stutter and made derogatory comments. The DON was informed of the allegation but did not report it within the mandated period. Additionally, the facility failed to report a resident-to-resident altercation in which one resident admitted to physically assaulting another on two separate occasions. Both residents were cognitively intact and had psychiatric diagnoses. The second incident resulted in visible injuries to the assaulted resident, and interviews revealed that the first incident had not been reported as required. Facility leadership acknowledged these reporting failures during interviews.