Failure to Follow Abuse Investigation Protocol and Timely Reporting
Penalty
Summary
The facility failed to follow its abuse investigation protocol after a resident reported rough handling by a CNA during care. The resident, who was cognitively intact and able to make his own decisions, reported to staff that the CNA did not stop providing care when asked multiple times. Both an LVN and an RN observed or were informed of the incident, and the RN acknowledged that the situation constituted an allegation of abuse. Despite facility policy requiring immediate suspension of any employee accused of abuse pending investigation, the CNA continued to work with other residents for the remainder of the shift. The RN did not report the incident to the Administrator immediately, nor was the CNA suspended as required by policy. Additionally, after the facility completed its investigation and determined the allegation was unsubstantiated, the Administrator failed to submit the results of the investigation to the California Department of Public Health, Licensing & Certification Program, Orange District Office within five working days, as required by both facility policy and regulation. The Administrator acknowledged that this reporting requirement was missed. These failures were confirmed through interviews with staff and review of facility policies and documentation.