Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State survey agency within the required two-hour timeframe. One resident, who had dementia and was not capable of making decisions, was flicked on the head by another resident who had chronic obstructive pulmonary disease, polyneuropathy, and depression. The incident was documented in the progress notes, with the aggressor admitting to flicking the other resident on the head to quiet him. There were no witnesses to the event, and the resident who was flicked did not sustain any injuries. Despite the documentation of the incident in the medical record, there was no evidence that the alleged abuse was reported to the California Department of Public Health within two hours as required. The Director of Nursing confirmed that the incident was not reported until seven days after it occurred, after being notified by the Social Service Director who discovered the documentation during a routine review. Interviews with nursing staff revealed a lack of awareness regarding the two-hour reporting requirement for allegations of abuse. The facility's policy required immediate reporting of all alleged violations to the appropriate agencies, specifying a two-hour window in cases of serious bodily injury. However, the staff involved did not follow this protocol, resulting in a delay in notifying the authorities about the incident. The failure to report the allegation in a timely manner was confirmed through interviews, record reviews, and observation.