F0600

K

Failure to Protect Resident From Mental Abuse and Delay in Abuse Reporting

Santee, California Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident with quadriplegia from mental abuse and intimidation by a CNA, and failure to recognize, report, and investigate the incident as abuse. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, asked a CNA to retrieve food from a refrigerator. The CNA responded by demanding that the resident say hello to him if she wanted something, repeating this in an angry manner. When the resident replied that she did not have to say hello if she did not want to, the CNA turned, yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident reported feeling scared and defenseless because of her limited mobility and slow wheelchair, and believed the CNA appeared as if he wanted to physically fight her. A second resident witnessed the incident and corroborated the account.

Following the incident, the resident called for help and reported to another CNA and the charge nurse that she was scared and did not feel safe with the CNA’s behavior. Staff observations and progress notes documented that the resident appeared in emotional distress at the time of the incident and remained upset and distressed over the following days, including expressing disbelief that the incident had occurred, stating she was not safe with the CNA, and planning to report to the police and Ombudsman. She stayed in bed for several days, refused to get out of bed, avoided social interaction, and declined to keep talking about the incident because she did not want to be retraumatized. Social work and psychotherapy notes documented that she did not feel safe with the CNA, feared he could lose his temper with her or other residents, and that the interaction elicited feelings of unsafety, a sense of being frozen, and led to three consecutive days in bed and avoidance of social interaction.

Despite these reports and observations, the charge nurse and CNA who first received the resident’s complaint did not report the incident to the administrator as an allegation of abuse, and the administrator did not interview the resident. The administrator stated she did not consider the incident to be abuse and believed the resident had chosen to file an internal grievance rather than have the incident reported externally. Nursing supervisors did not relay the resident’s statements of fear and emotional distress to the administrator, and one supervisor reported only the CNA’s version of events, omitting the resident’s account. The facility did not complete and submit the SOC 341 abuse report form or report the allegation to the state agency until three days after the incident, and the internal investigation did not begin until that time. During this delay, the CNA, who had a documented history of behavioral concerns noted by the Directors of Staff Development and other staff (including arrogance, resistance to instruction, rudeness, shouting at residents, and unprofessional conduct), continued to be assigned to provide care to residents on two other units, exposing 63 residents to a staff member whose conduct toward the resident had been described by multiple staff as abuse and emotionally distressing.

The facility’s own policy defined mental abuse as verbal or nonverbal conduct causing or having the potential to cause humiliation, intimidation, fear, or degradation, including yelling, hovering to intimidate, threatening residents, and depriving a resident of care. Staff interviews, including those of CNAs, the charge nurse, social worker, and Directors of Staff Development, characterized the CNA’s conduct toward the resident as verbal or emotional abuse and intimidation. The facility’s abuse policy required all employees to act as mandated reporters, to immediately report suspected abuse to the administrator and external agencies within specified time frames, to initiate an investigation promptly, and to ensure that staff accused of abuse generally did not have contact with residents during the investigation. These requirements were not followed in this case, leading to a failure to protect the resident from mental abuse and intimidation and a failure to protect other residents from potential abuse. Surveyors determined that this failure to identify and act on the resident’s allegation as abuse resulted in psychosocial harm to the resident, including feeling scared and unsafe, withdrawal from socialization, and ongoing worry, and posed an immediate jeopardy to the safety and well-being of the other residents on the units where the CNA was assigned during the delay in reporting and investigation.

Removal Plan

• Immediately remove any staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse from direct resident care pending investigation.
• Confirm through facility leadership that no residents are currently exposed to staff under investigation.
• Observe the affected resident by nursing staff after the incident and place the resident on monitoring for emotional distress every shift.
• Have the Behavioral Health Program Coordinator attempt to see/assess the affected resident (with follow-up attempts as needed).
• Provide access to facility psychologist and social workers to the affected resident (and all residents) as needed.
• Regardless of investigation type (complaint vs. abuse), if a staff member is an alleged perpetrator, remove the staff member from direct patient care pending abuse investigation results or determination the complaint does not involve abuse.
• Require staff reporting incidents to the Abuse Coordinator to provide thorough and accurate statements based on gathered knowledge, observations, preliminary interviews, and the resident’s psychosocial disposition.
• Report allegations or suspicions of abuse promptly according to required regulatory timelines and submit Form SOC 341.
• Educate staff that they are mandated reporters with the right and obligation to report abuse or suspicion of abuse regardless of others’ opinions.
• Ensure staff are educated and have access to the SOC 341 form and abuse policies/procedures for guidance.
• Provide facility-wide in-service education on staff training for abuse, neglect, and exploitation prevention, with staff on days off/leave/PTO completing education upon return and prior to providing patient care.
• Continue a thorough investigation of the allegations, including resident interviews, staff interviews, witness interviews, employee personnel file review, resident record review, and other items as necessary.
• Submit all investigation results to CDPH within required timelines.
• Have the Administrator/Abuse Coordinator review abuse investigation protocols using the Abuse Investigation Checklist with the Assistant Administrator, DON, ADON, QA nurse, other ADON, and the Behavioral Health Program Coordinator before assuming direct patient care.