Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after an incident involving two residents. One resident, who had severe cognitive impairment, a history of delusions, and physical and verbal behaviors directed toward others, reportedly approached her roommate, yelled at her, threw water, and struck her with a water bottle multiple times while the roommate was in bed. The incident was witnessed by a CNA, who heard yelling and observed the resident standing close to the roommate, with a water pitcher on the ground nearby. Despite these observations and the roommate's report of being hit, the CNA did not report the incident, believing no one was hurt and assuming the administrator was already aware of ongoing issues between the two residents. The roommate, who was the victim in this incident, stated that she had previously informed nursing staff about repeated invasions of her personal space and taking of her belongings by her roommate, but no action had been taken. On the night of the incident, she used her call light and yelled for help, but no staff responded. She also contacted her responsible party, who, upon hearing the commotion over the phone, called the police for a wellness check. The police report confirmed the details of the incident, including the physical altercation and the lack of immediate staff intervention. The Director of Nursing (DON) only became aware of the incident the following day during a staff huddle and confirmed that the incident should have been reported immediately to the administrator, police, Ombudsman, and CDPH. The administrator was present in the building at the time of the incident but was not informed until the next day. The facility's policy required reporting all allegations of abuse within two hours, but this protocol was not followed, resulting in a delay in notifying authorities and initiating an investigation.