Failure to Implement Abuse Reporting Protocols Following Repeat Deficiency
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) Committee implemented action plans to correct previously identified abuse allegation deficiencies. Despite in-service training and a performance improvement plan that required immediate reporting of abuse allegations to the California Department of Public Health (CDPH), the ombudsman, and law enforcement, staff did not follow these protocols. Specifically, when a resident reported to Social Services that a Certified Nursing Aide (CNA) was rough while shaving him, the Director of Staff Development (DSD) was notified and interviewed the CNA but did not suspect abuse and did not report the allegation as required. The Director of Nursing (DON) and the Administrator (ADM) were not informed of the allegation until several days later, contrary to the facility's established procedures. The review of grievance and complaint forms revealed that incidents were not promptly communicated to the appropriate authorities or facility leadership. The DON confirmed that she was not made aware of the resident's allegation until weeks after the incident, and that the required reporting to CDPH, the ombudsman, and law enforcement did not occur prior to the internal investigation. This failure to follow the facility's abuse reporting protocols represents a repeat deficiency and demonstrates a breakdown in communication and adherence to established procedures for handling abuse allegations.