Failure to Timely Report and Document Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse and did not submit the results of their investigation to the California Department of Public Health within the required timeframe. This deficiency was identified through observation, interviews, and record review, which revealed that an incident occurred where one resident struck another in the face while both were in their wheelchairs in a hallway. The incident was witnessed by the Human Resource Director (HRD), who immediately separated the residents and notified the floor nurse, DON, and Administrator. However, there was no documentation of the incident in the progress notes or care plans for either resident, and the event was not reported to the Department as required. The residents involved had significant medical histories: one had severe cognitive impairment and was unable to recall the incident, while the other admitted to hitting in self-defense but could not remember the date. The HRD confirmed the incident was captured on video and occurred on Halloween, but neither the DON nor the Director of Staff Development (DSD) were aware of the event until interviewed by surveyors. The DON stated that staff were expected to separate residents, report the incident, and follow up with assessments and monitoring, but these steps were not documented or completed. A review of facility records and Department logs confirmed that no abuse allegations were reported during the relevant period, and the facility's policy required timely identification, investigation, and reporting of abuse allegations. The management team, including the Administrator, DON, and others, were present in the facility on the day of the incident, yet the required reporting and documentation did not occur, impeding the Department's ability to conduct a timely investigation.