Failure to Timely Report Alleged Abuse Involving Unauthorized Restraint
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the California Department of Public Health (CDPH) and the ombudsman within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, dementia, and type 2 diabetes, who was found with a linen sheet wrapped around his legs and tied to the bedframe. Multiple staff members, including CNAs and RNs, observed the resident with his legs restrained by a sheet, which was not authorized by a physician and was not in accordance with facility policy. The staff immediately notified supervising nurses, and the sheet was removed upon discovery. Interviews and documentation revealed that the CNA responsible for applying the sheet did so in an attempt to prevent the resident from sliding off the bed, but acknowledged that this was not the proper method and was not how he was trained. The facility's investigation substantiated that the CNA used an unauthorized restraint, and the action was identified as a suspicion of involuntary restraint. Staff members who witnessed the incident described the restraint as tight, preventing the resident from moving his legs, and recognized it as a form of abuse. The CNA involved was suspended pending investigation and later resigned. Despite the immediate internal response, the facility administrator, who served as the abuse coordinator, did not report the incident to CDPH and the ombudsman within two hours of becoming aware of the situation. Both the administrator and the director of nursing stated that the delay was due to the absence of serious bodily injury. However, facility policy and regulatory requirements mandate that all allegations of abuse be reported immediately, but not later than two hours if the alleged violation involves abuse, regardless of injury. The delay in reporting constituted a failure to comply with mandated reporting requirements.