Failure to Timely Report Alleged Abuse and Prevent Reassignment of Accused CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and to protect a resident from further contact with the alleged perpetrator, as required by its Abuse Prohibition Policy and Procedures. The policy, dated 2/23/2021, required that upon receiving information about suspected or alleged abuse, the designee report the allegation to CDPH, local law enforcement, the Ombudsman, and other required agencies within two hours, initiate an investigation within two hours, document witness interviews, and protect patients from further harm during the investigation. On 1/11/2026 at 10:00 AM, a cognitively intact resident with hemiplegia and hemiparesis following a cerebral infarction, and the resident’s family member, reported to an LVN that a CNA had been rough while turning the resident and had hurt the resident. The LVN documented the complaint in a Change in Condition Evaluation and reassigned the CNA for the remainder of that shift but did not report the allegation to the DON or Administrator, assuming the RN on duty would do so. As a result, the Administrator, who is the facility’s abuse coordinator, was not informed and no required external reports were made within the mandated two-hour timeframe. The resident’s admission and assessment records showed that the resident had the capacity to understand and make decisions and was cognitively intact. The family member stated that the resident’s roommate, who was alert, confirmed hearing the resident scream while the CNA was changing the resident’s briefs. The family member reported the incident to the LVN and RN and specifically requested that the CNA not be assigned to the resident again. Despite this, staffing assignment sheets showed that the same CNA was again assigned to the resident on the night shift of 1/12/2026. The family member later reported that when she arrived the next morning, the resident stated no one had checked on or changed him during the night, and the family member found the resident’s diaper soaking wet; the resident identified the assigned CNA as the same CNA previously reported for rough handling. The Administrator confirmed she was unaware of the initial complaint and stated that, had she been informed, she would have initiated the abuse investigation and reporting process as outlined in the facility’s policy.
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