Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one with violent behavior, restlessness, and agitation, and another with dementia. According to the nurse's notes, one resident was observed striking and being verbally abusive to their roommate, as well as taking items from the roommate's closet. The incident escalated to physical aggression, including kicking and slapping, as witnessed by a licensed nurse. The nurse reported the incident to the direct supervisor but was not instructed to complete the required SOC341 form for suspected dependent adult/elder abuse. During interviews, the licensed nurse confirmed the incident was not reported to the state, and the administrator stated that all cases of abuse, even those between residents with dementia and without injury, should be reported to law enforcement, the ombudsman, and the California Department of Public Health within two hours. A review of the facility's policy indicated that all allegations must be investigated and reported within federally required timeframes. The failure to report this incident constituted a deficiency in mandated reporting procedures.