F0609

D

Failure to Immediately Report Witnessed Physical Abuse by Therapist

Glendale, California Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an incident of physical abuse by a physical therapist toward a resident to the Administrator within the required timeframe, as outlined in the facility’s Abuse Prevention Program and Abuse Investigation & Reporting policies. On 02/23/2026, while beginning physical therapy, Resident 1 entered the rehabilitation room and touched PT 1 on the back of the head to get his attention. In response, PT 1 rotated his chair and struck the resident once on the right thigh with an open hand, producing a loud sound described by PT 2 as similar to slamming hands on a desk. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction and had documented capacity to understand and make decisions, immediately protested, stating, "no, you can't do that" and "you beat me," and later reported feeling angry, assaulted, and that the slap stung his leg.

Despite witnessing the event, neither PT 1 nor PT 2 reported the incident to the Administrator on the day it occurred. PT 2 stated that she believed there was a 24-hour reporting window and wanted to give PT 1 an opportunity to report the incident himself, and only reported it the following day to the Director of Rehabilitation after learning PT 1 had not done so. PT 1 stated he did not notify the Administrator or Director of Rehabilitation because, in his experience, when he reported concerns, no action was taken. During this time, therapy continued in the same room with both therapists present, and Resident 1 stated that no one asked him how he was or whether he was okay following the incident.

Interviews with facility leadership confirmed that the incident met the definition of physical abuse and should have been reported immediately. The DON stated the incident between Resident 1 and PT 1 was considered physical abuse and should have been reported immediately to facility administration in accordance with facility policy and abuse reporting requirements. Review of the facility’s Abuse Investigation & Reporting, Abuse Prevention Program, and Abuse and Neglect Clinical Protocol policies showed that all allegations or incidents of abuse, neglect, exploitation, misappropriation, mistreatment, or injuries of unknown origin were to be promptly and immediately reported to appropriate facility management and external agencies, and that management and staff were required to address suspected or identified abuse and report it in a timely manner. The failure of PT 1 and PT 2 to immediately report the witnessed physical abuse resulted in a delay in the facility’s investigation and protection of Resident 1 from further abuse.