Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. The incident involved a Certified Nursing Assistant (CNA) placing a towel over the resident's head and mouth and telling the resident to be quiet. Another CNA witnessed the event but did not immediately report it to a supervisor, instead choosing to wait and report it directly to the Director of Staff Development (DSD) two days later. The facility's policy and federal requirements mandate immediate reporting of such allegations, but the CNA misunderstood the reporting timeframe and delayed notification. The resident involved had a history of cerebral infarction and fluctuating decision-making capacity. Following the incident, the resident was assessed and found to have no injuries or distress, and the physician was notified. Interviews with facility staff confirmed that the expectation was for immediate reporting of abuse allegations, but the delay resulted in the incident not being reported to CDPH until two days after it occurred. Documentation showed that the CNA had previously acknowledged understanding the mandatory reporting requirements.