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F0580
D

Failure to Notify Physician of Abuse Allegation

San Diego, California Survey Completed on 06-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the attending physician of an abuse allegation involving a resident who was admitted with a diagnosis including skin cancer. During an unannounced onsite visit, the resident reported to surveyors that a CNA had been rough while turning him in bed, which was considered an abuse allegation by facility staff. Interviews with the licensed nurse and the charge nurse confirmed that such allegations should be reported to the Director of Nursing, the administrator, the resident's attending physician, and the family. However, a review of the resident's electronic medical record and interviews with the charge nurse and DON revealed there was no documentation that the attending physician had been notified of the abuse allegation. The facility's policy and procedure on reporting and investigating abuse, neglect, exploitation, or misappropriation required immediate notification of the attending physician when abuse is suspected. Despite this policy, both the charge nurse and DON confirmed that there was no evidence of physician notification in this case. The DON acknowledged the importance of physician awareness to ensure the resident's safety and proper evaluation, but the required notification did not occur.

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