Failure to Timely Report Resident’s Allegation of Physical Abuse to Required Agencies
Penalty
Summary
The facility failed to follow its abuse reporting policy and regulatory requirements when an allegation of physical abuse was made by a resident and was not reported to the California Department of Public Health (CDPH), local law enforcement, or the Ombudsman within two hours. Resident 8, who had diagnoses including schizophrenia, bipolar disorder, and cellulitis of the left lower limb, was cognitively intact per the MDS dated 11/12/2025 and required only supervision or touching assistance for several ADLs. During an interview with a surveyor on 1/26/2026, the resident stated that about a month earlier, while sitting on his bed and reading, someone hit him very hard on his right ribs, cracking them, and that he did not see who hit him but only saw a shadow. The allegation was documented in the resident’s records. The care plan dated 1/27/2026 noted that the resident had alleged being struck by a shadow a month prior, and interventions included close monitoring of the resident’s whereabouts, room visits every two hours and as needed, and following the abuse prohibition protocol. An SBAR dated 1/26/2026 recorded that the resident told the surveyor that someone had struck him on his rib and that he only saw a shadow. Nursing staff, including a RN supervisor, reported that the DON was notified of the resident’s statement that he had been struck on his right side by a shadow. Despite this, the allegation was not reported to external agencies as required by facility policy. The DON acknowledged that an allegation of abuse involving a staff member hitting a resident should be reported to the Administrator, who serves as the abuse coordinator, and that an SOC 341 form should be completed and sent to CDPH, the Ombudsman, and the police. The DON and Administrator both confirmed that the allegation was not reported when they were informed, and the DON stated she did not report it because she attributed the resident’s statement to his mentation and behavior related to his mental illness. Review of the facility’s abuse reporting and investigating policy, revised September 2022, showed that all reports of resident abuse must be immediately reported—defined as within two hours—to the state licensing/certification agency, Ombudsman, and law enforcement, which did not occur in this case.
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