Failure to Timely Report Resident-to-Resident Altercation to Authorities
Penalty
Summary
The facility failed to report a witnessed resident-to-resident altercation involving two residents to the California Department of Public Health (CDPH), as required by law and facility policy. The incident involved one resident with severe cognitive impairment and fluctuating behavior, who attempted to strike another resident with moderate cognitive impairment and a history of delusions. The altercation was witnessed by two Certified Nursing Assistants (CNAs), who responded to calls for help and observed the aggressive behavior. Both CNAs reported the incident to a Licensed Vocational Nurse (LVN), but the LVN did not notify the administrator, document the incident, or initiate a report to CDPH. A review of the clinical records for both residents revealed no documentation of the altercation, and interviews with the LVN and Registered Nurse Supervisor (RN) confirmed they were unaware of the incident. The LVN only reported a complaint of wrist pain as an injury of unknown origin, without linking it to the altercation. The Director of Nursing (DON) stated that any allegation of abuse, including resident-to-resident altercations, should be reported within two hours, and acknowledged that yelling for help should have triggered an abuse report. The facility's policies require prompt reporting and investigation of all allegations of abuse, including resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate authorities, and absence of timely reporting delayed an onsite investigation by CDPH and did not ensure the safety and protection of all residents in the facility.