Failure to Submit Required Abuse Investigation Summary to State Agency
Penalty
Summary
The facility failed to submit a five-day summary of investigation to the California Department of Public Health (CDPH) following an abuse allegation involving a resident. The resident, who had a history of cerebrovascular disease, was observed with a dark purple discoloration on the left forearm and bandages on both hands. The resident reported being attacked by a staff member, which resulted in bruises and skin tears. The resident's son also reported these injuries and requested clarification on their cause. Interviews with staff, including the DON and a licensed nurse, revealed uncertainty about how the injuries occurred. Despite completing an internal investigation into the alleged abuse, the DON acknowledged that the required five-day written summary of the investigation was not submitted to CDPH. The facility's policy mandates that all reports of resident abuse, including injuries of unknown origin, be reported to local, state, and federal agencies, with a written report of findings provided within five working days. This omission constituted a failure to comply with both regulatory requirements and the facility's own policy.