Failure to Timely Report Suspected Abuse to State Authorities
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 becoming aware of a resident's injury. A resident, admitted with conversion disorder and major depressive disorder and assessed as having intact cognition and decision-making capacity, returned from the hospital with right eye discoloration. The injury was identified as a right periorbital hematoma, which is considered a potential sign of physical abuse according to the facility's own policies. The police initially informed an LVN about the resident's eye discoloration, and the Director of Nursing later confirmed that the facility became aware of the injury upon the resident's return from the hospital. Despite the facility's policy requiring immediate reporting of abuse allegations to state authorities, the incident was not reported to CDPH as mandated. Staff interviews and record reviews confirmed that the required notification did not occur. The facility's policies also specify that facial injuries such as black eyes and bruising are to be treated as potential abuse and reported accordingly, but this protocol was not followed in this case.