Failure to Timely Report Suspected Abuse and Injuries
Penalty
Summary
The facility failed to report multiple incidents of suspected physical and verbal abuse, as well as an injury of unknown origin, to the appropriate state and federal authorities within the required two-hour timeframe. Certified Nursing Assistant (CNA) 1 witnessed another CNA (CNA 2) roughly handling, slapping, and restraining a resident during care, resulting in a skin tear. Despite witnessing this on several occasions, CNA 1 delayed reporting the incident for 18 hours, only notifying a Licensed Nurse (LN A) the following day. Additionally, CNA 1 observed CNA 2 placing a pillow over another resident's face and verbally telling her to be quiet, but did not report this for 35 hours, eventually informing the Director of Nursing (DON). Both incidents were not reported to the California Department of Public Health (CDPH), the Ombudsman, or the Sheriff's office within the mandated timeframe. Further review revealed that LN A, after being informed of the abuse, did not report the suspected abuse to the required authorities, instead only sending an email to the DON. The DON confirmed that neither LN A nor CNA 1 followed the correct reporting procedures. Another nurse (LN B) overheard staff discussing CNA 2's rough treatment of residents but did not report these concerns. LN B also discovered a bruise of unknown origin on a resident's arm but did not investigate or report the injury, assuming it was accidental. The DON later confirmed that no investigation was conducted to determine the cause of the bruise and that it should have been reported. The residents involved had significant cognitive impairments and were dependent on staff for care, with one resident unable to make her own health care decisions and another exhibiting moderate cognitive impairment and behavioral symptoms. The facility's policy and procedure on abuse prevention and reporting did not specify the requirement to notify CDPH and the Ombudsman within two hours of suspected abuse. The DON acknowledged that the policy was incorrect and needed revision. The failure to report these incidents promptly allowed for continued abuse and unaddressed injuries among vulnerable residents.