Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to report four separate allegations of abuse within the required two-hour timeframe to the California Department of Public Health (CDPH). In one incident, two residents with significant cognitive impairments and BIMS scores of 0 were involved in a resident-to-resident sexual abuse event. Staff observed one resident attempting to open the brief of another resident during the night. Although the incident was reported internally, the team initially decided it was not reportable, and the mandated report to CDPH was delayed until a physician later determined it should be reported. In another incident, a staff member observed inappropriate touching between two residents in a common area. The staff member reported the event to the team leader, who dismissed the concern, stating that the residents were friends. The incident was later discussed in a team huddle, but there was confusion among staff about whether the event was reportable. The mandated report to CDPH and other agencies was delayed as the team attempted to contact the family of one resident and debated the necessity of reporting, despite facility policy requiring reporting within two hours. Facility policy clearly states that all employees, contractors, and volunteers are mandated reporters and must report alleged abuse to CDPH, the Ombudsman, and Nursing Operations within specified timeframes. However, in both cases, staff failed to adhere to these requirements, resulting in delayed reporting of abuse allegations. Interviews with staff and review of clinical notes confirmed that confusion about what constitutes a reportable event and internal decision-making processes contributed to the reporting delays.