Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required two-hour timeframe to the ombudsman, local police department, and California Department of Public Health (CDPH), as mandated by the facility's Abuse and Neglect Prohibition Policy. The incident occurred when a certified nurse assistant (CNA) heard a commotion and found one resident holding a slipper and another resident reporting that she had been threatened with it. Both residents had severely impaired cognition and memory, with one diagnosed with paranoid schizophrenia and bipolar disorder, and the other with major depressive disorder and hypertension. The incident was documented in the residents' records and reported internally to the Director of Nursing (DON) and the Administrator (ADM), but not to the required external authorities. Interviews with staff and residents confirmed that the resident with cognitive impairment became agitated, believed her bed was occupied by another, and threatened the other resident with a slipper. The threatened resident expressed fear during the incident. Staff responded by separating the residents and moving one to a different room. Despite these actions, the facility did not classify the event as abuse and therefore did not escalate or report it to CDPH, the ombudsman, or the police as required by policy. A review of the facility's policies confirmed that all alleged violations involving abuse must be reported immediately, but not later than two hours, to the appropriate authorities. The facility's failure to report the incident as required resulted in underreporting of abuse allegations and a failure to follow established abuse protocols.