Failure to Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and mandated reporting policies when a resident’s allegation of physical abuse by a nurse was not reported to the State Survey Agency or law enforcement. The resident, who had diagnoses including ventilator dependence, unspecified intellectual disabilities, muscular dystrophy, and a myoneural disorder, was cognitively intact with a BIMS score of 13. The resident reported that in 2025, when a wall-mounted vital signs machine failed during a vital signs check, an RN entered the room and slapped her arm. She stated she reported this incident to the Social Services Director (SSD), who responded that it would be her word against the RN’s. Social services notes from late June documented the resident’s allegation that an RN had smacked her right arm two days earlier and indicated the allegation would be investigated, but no SOC 341 report corresponding to that June allegation was found. Further social services documentation from October showed the resident again reported to a Nurse Practitioner (NP) that the RN had smacked her arm, referring back to the June incident, and that SSD was investigating. A SOC 341 completed in late October described the NP asking the resident about the previously documented abuse allegation and urging the facility to report the incident to the Ombudsman. The SOC 341 also documented that the June incident had been discussed with the physician and Regional Case Manager, who concluded the resident had a history of fabricating stories, and therefore no SOC 341 was filed at that time. The SOC 341 explicitly noted that the abuse allegation reported to the NP in October was not reported to the State Agency, and the section listing agencies to which the incident was reported was left blank. The Administrator later stated that the incident was reported only to the Local Ombudsman and that no written report was sent to the State Survey Agency, despite facility policy requiring the Administrator to report suspected abuse or allegations to the California Department of Health within 24 hours.
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