F0609

D

Failure to Timely Report Alleged Resident-to-Resident Physical Abuse

Long Beach, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to implement its abuse prevention policy by not reporting an allegation of physical abuse between two residents to the California Department of Public Health (CDPH) within two hours of the occurrence. One resident, admitted with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, osteoarthritis, and schizophrenia, required substantial/maximal assistance with care per the Minimum Data Set (MDS). The other resident, admitted with chronic kidney disease, type 2 diabetes mellitus, heart disease, and gout, had documented capacity to understand and make decisions and required moderate assistance for bed mobility and transfers. An occupational therapy assistant reported that the second resident allegedly hit the first resident on the head with a cane while the first resident was lying on his side and coughing.

Following the allegation, the LVN assessed both residents and informed the registered nurse supervisor (RNS), who then took steps such as relocating the first resident and removing the second resident’s cane and notifying the physician. The administrator stated that, per facility policy and the abuse prevention and management procedure dated 1/1/2026, law enforcement must be notified immediately or as soon as practicably possible, and a written SOC341 report must be sent to the Ombudsman, law enforcement, and CDPH immediately, but not later than two hours after forming the suspicion if the events result in serious bodily injury. However, the administrator acknowledged that administration conducted its own investigation first, and the SOC341 was faxed to CDPH and the Ombudsman approximately seven hours after the allegation, exceeding the required two-hour reporting timeframe.