Failure to Timely Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses within the required two-hour timeframe to the California Department of Public Health. The resident, who had a history of behavioral issues and required significant assistance with daily activities, was involved in an altercation where a registered nurse (RN) threw juice at the resident after the resident had thrown juice at the nurse. This incident was witnessed by a certified nursing assistant (CNA), who did not report the event as required due to being occupied with other duties. The facility's policies and procedures, as well as staff interviews, confirmed that all staff are mandated reporters and are required to report any suspected abuse, neglect, or mistreatment immediately, and no later than two hours after the incident. Despite this, the CNA failed to report the incident to the Abuse Coordinator or Administrator. The RN involved in the incident later sent a text message to another RN describing the event, but this message was not seen until the following day, further delaying the reporting process. Record reviews and staff interviews indicated that the facility's abuse prevention and reporting policies were not followed in this case. The delay in reporting the incident resulted in a violation of the resident's rights and had the potential to delay the investigation of abuse and expose the resident to further harm. The deficiency was identified through interviews, record reviews, and examination of facility policies.