Failure to Conduct Thorough Abuse Investigation and Timely Reporting
Penalty
Summary
The facility failed to follow its Elder Abuse Prohibition and Prevention policy and procedure in response to a resident-to-resident physical and verbal altercation involving two residents. The investigation was incomplete, as the staff member assigned to investigate, an LVN, only interviewed the staff witnesses and the residents directly involved. The LVN did not interview other residents, review the medical records of the involved residents for prior history of aggression or behaviors, or speak to other staff who had provided care to the residents before the incident. The LVN also stated she was not trained to investigate abuse and was only instructed to interview witnesses and the involved residents. The documentation was limited to statements on the SOC 341 form, without a comprehensive review as required by facility policy. Additionally, the facility did not submit a 5-day investigation report to the California Department of Public Health (CDPH) or the LTC ombudsman, as required by both facility policy and state law. The administrator confirmed that such reports were not sent, indicating a failure to report the results of the investigation to the appropriate authorities within the mandated timeframe. This omission resulted in the potential for an incomplete investigation and lack of protection for the residents involved.