Failure to Timely Report Resident-to-Resident Altercation and Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident altercation within the required 24-hour timeframe to the California Department of Public Health (CDPH), as mandated by its own Abuse Reporting and Investigation Policy and Procedure. Two residents, both with severe cognitive impairments and significant behavioral and communication challenges, were involved in an incident where one resident sustained a visible red mark on the forehead. Despite the presence of physical evidence and staff awareness of the altercation, there was no documentation of the incident in either resident's clinical records, nor was there evidence of notification to responsible parties or physicians. Multiple staff members, including a staff coordinator and two licensed nurses, witnessed or were informed of the incident and observed the injury. The staff coordinator documented the injury with a photograph, and both nurses confirmed that the administrator was notified of the event. However, the administrator instructed staff that he would handle the situation and directed them not to report the incident further. As a result, the incident was not reported to law enforcement, the Ombudsman, or CDPH as required by facility policy and state regulations. Interviews with staff and review of facility records revealed that no Change in Condition Evaluations were completed for either resident following the altercation, and no follow-up investigation or interviews were conducted. The administrator later acknowledged the lack of documentation and reporting, and could not provide an explanation for the failure to follow required procedures. The facility's policy clearly states that all allegations of abuse, including injuries of unknown source, must be reported to appropriate agencies within specified timeframes, which was not done in this case.