Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents. One resident, who was cognitively intact and dependent on staff for activities of daily living (ADLs), reported to a CNA that another resident, who had severely impaired cognition and a diagnosis of schizophrenia, poured water on her face while she was receiving care. The affected resident described feeling as though she was drowning and was observed crying with her upper body soaking wet. The CNA stated that upon returning to the room, she found the resident in distress and was informed of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse to the DON or ADM, the CNA did not report the allegation to the appropriate personnel. The DON confirmed she was unaware of the incident and had not been informed by the CNA. As a result, the incident was not reported to the California Department of Public Health (CDPH) or the ombudsman, preventing a timely investigation and risking the loss or forgetting of critical information.