Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe, as mandated by federal and state law. Specifically, a resident with dementia, carcinoma, and agitation was found on the floor outside the bathroom, in pain and alleging that another resident had pushed them. The incident resulted in a significant injury—a comminuted, mildly displaced, impacted intertrochanteric fracture of the right hip—requiring transfer to an acute care hospital. The resident's medical records indicated cognitive impairment and a need for staff assistance with daily activities. Despite the resident's clear allegation of being pushed, the staff members present at the time, including an LVN and an RN, did not report the abuse allegation to the Director of Nursing (DON) or the Administrator (ADM) as required by facility policy. The LVN assumed the RN would report the incident, but neither followed up or ensured the allegation was communicated to the appropriate authorities. The DON and ADM only became aware of the abuse allegation the following day, after the injury had already been reported to the state agency as a fall, but not as a potential abuse incident. Upon learning of the abuse allegation, neither the DON nor the ADM reported it to the California Department of Public Health, the ombudsman, or local law enforcement within the required two-hour window. Both acknowledged during interviews that the facility's policy and procedure for reporting abuse was not followed. The failure to report the allegation immediately resulted in a delay in investigation and notification to the proper authorities, as required by both facility policy and regulatory requirements.