Failure to Immediately Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the appropriate authorities, as required by both facility policy and state law. A resident alleged that a CNA shook their shower chair, pulled and yanked their hands, and kicked them during a shower. The resident reported this incident to other CNAs and a nurse practitioner, but there was no documentation of the allegation in the resident's medical record. The facility's policy requires immediate reporting of suspected abuse to the administrator and various agencies, but neither the Administrator nor the DON were aware of the allegation until it was reported to the state months later. Interviews revealed that the CNA involved did not report the resident's allegation, stating she did not believe the accusation was true. The DON confirmed that all staff are mandated reporters and should report any abuse allegations immediately. The failure to report the allegation in a timely manner resulted in a delay in notifying the CDPH, Ombudsman, and law enforcement, as well as a lack of internal documentation and investigation at the time the incident was alleged to have occurred. The resident had a history of moderately impaired cognition but was assessed as having the capacity to understand and make decisions.