Failure to Timely Report Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Reporting and Prevention policy and the requirements of section 1150B of the Act and state law for timely reporting of a reasonable suspicion of a crime. Facility policy required that alleged abuse resulting in serious bodily injury, including physical abuse and resident-to-resident altercations with actual harm, be reported to CDPH, the ombudsman, and local law enforcement immediately, but no later than two hours after forming the suspicion. On the date of the incident, two residents were involved in an altercation at approximately 1620–1700 hours when one resident, who had severe cognitive impairment per MDS, pushed another resident who was attempting to enter her room. Multiple staff interviews confirmed that the pushing incident was reported to nursing staff on the same day, and that the pushing resident admitted to giving the other resident a “little shove” to stop her from entering the room. The pushed resident, who lacked capacity to understand and make decisions per H&P, was found on the floor near the room, crying and complaining of left hip pain rated five out of ten. Progress notes documented the event as an unwitnessed fall, and subsequent radiology showed fractures of the left superior and inferior pubic rami, with the age of the fracture indeterminate. Despite the facility’s policy that any allegation of physical abuse and resident-to-resident altercations with actual harm be reported within two hours, the RN did not notify CDPH, the ombudsman, or local law enforcement within that timeframe. Instead, the SOC 341 report identifying one resident as the alleged victim and the other as the alleged abuser was submitted the following day at 0906 hours, outside the required two-hour reporting window. The DON later acknowledged that the incident should have been reported within two hours and that incorrect information about injury status had been relayed to him.
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