Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Reporting and Investigations policy by not thoroughly investigating allegations of resident abuse involving two residents. Both residents had significant cognitive and mental health impairments, with one resident having severe dementia and fluctuating decision-making capacity, and the other diagnosed with major depressive disorder, psychosis, and schizophrenia. Despite these vulnerabilities, there was no documentation in the clinical records regarding a resident-to-resident altercation that occurred between them. Certified Nursing Assistants (CNAs) reported witnessing an incident where one resident attempted to strike another while the latter was in bed. The CNAs responded to calls for help and observed aggressive behavior, subsequently reporting the incident to a Licensed Vocational Nurse (LVN). However, the LVN denied knowledge of the altercation, did not notify the administrator, failed to document the incident, and did not initiate a report to the California Department of Public Health (CDPH). The Registered Nurse Supervisor (RN) was also unaware of the incident, and there was no clinical documentation of the event. Interviews with facility leadership confirmed that abuse allegations should be investigated promptly, with intervention required for any type of abuse. The facility's policies require prompt reporting, investigation, and documentation of resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate personnel, and absence of an investigation into the reported altercation constituted a failure to follow established procedures, resulting in a delay in the onsite investigation by CDPH and a deficiency in protecting residents from potential abuse.