Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe after becoming aware of the incident. The event involved two residents, one with severe cognitive impairment and another with moderate cognitive impairment and a diagnosis of schizophrenia. The incident occurred when one resident, upset after being called a derogatory name, intentionally pushed her wheelchair into the other resident's wheelchair twice, causing the latter's head to move backward. Staff members who witnessed or were informed of the incident reported it up the chain of command, but the Assistant Director of Nursing and the Administrator did not consider the event to be abuse and therefore did not report it to the California Department of Public Health (CDPH) or other required authorities. The facility's policy and procedure required that all allegations or suspicions of abuse be reported immediately, but not later than two hours after the allegation is made, to both the facility Administrator and the State Survey Agency. Despite this, the Administrator acknowledged being notified of the incident but chose not to report it, as he did not consider it abuse. This failure to report resulted in the inability of CDPH to conduct an immediate investigation and created the potential for information to be lost or forgotten.