F0609

D

Failure to Report and Investigate Resident-to-Resident Abuse Allegations

San Diego, California Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and thoroughly investigate two separate allegations of resident-to-resident abuse, and to submit required 5‑day follow‑up investigation reports to the State Survey Agency, as required by facility policy and regulation. In the first incident, one resident with a history of right tibia fracture, hypertension, and alcohol dependence, and with moderate cognitive impairment but independent functional abilities, reported to Social Services that he had kicked his roommate in the lower torso after the roommate allegedly threatened him over television volume. The Social Services Assistant (SSA) documented that the resident admitted to kicking his roommate and stated he had not reported it earlier because he feared being arrested. The SSA’s original electronic note clearly described the kick and her plan to notify administration and the DON, but this note was later struck out as “incorrect documentation” at the DON’s direction, and a handwritten follow‑up note omitted the physical act of kicking and stated that further investigation did not warrant any change.

The roommate, who had intact cognition, epilepsy, and other medical conditions but no behavioral issues, later told surveyors that his former roommate had kicked him, causing him to fall back onto his wheelchair and sustain a bruise on his lower back from the brake lever. His EMR contained a nurse’s note documenting a fall in his room with a large reddish discoloration on his back, consistent with his description, but there was no documentation in the EMR of any abuse investigation, IDT follow‑up, or reporting to the Administrator (who was the abuse coordinator), physician, responsible party, police, ombudsman, or the State Survey Agency. The Quality Nurse, SSA, ADON, and Charge Nurse all described a facility process that required immediate separation of residents, head‑to‑toe assessments, reporting to the Administrator, and documentation of investigation and care plan changes, but they were unable to locate any such follow‑up in the record. The Administrator confirmed he had not been notified of this allegation at the time, did not initiate an investigation, and did not submit a 5‑day investigation summary or required external reports. The DON acknowledged she considered the allegation to be resident‑to‑resident abuse, did not investigate because she believed it was only verbal and that the alleged aggressor had been discharged, and asked the SSA to strike the original note because it appeared to describe unreported abuse.

In the second incident, a resident with moderate cognitive impairment, sepsis, UTI, epilepsy, and malignant brain neoplasm reported that someone had thrown water on him while he was resting in bed and complained that the person said he snored too much. Two CNAs, who had earlier showered and dressed him dry, later found him soaking wet; the resident told them that “the man in the wheelchair” had thrown water on him. Both CNAs and the Charge Nurse identified this as resident‑to‑resident abuse, stated that they immediately reported it to the DON and Administrator via verbal report and text message to the IDT, and the EMR contained a nurse’s note documenting that the resident claimed someone threw water on him and that his gown was wet. Another resident reported that the suspected roommate frequently called him derogatory names, and nursing notes documented that this suspected roommate had a history of verbal aggression, threatening behavior, and staff concern that he might throw water or otherwise harm his roommate if disturbed by noise. Despite this, there was no documentation of a completed abuse investigation, separation of residents, or IDT follow‑up in the EMR, and the Administrator acknowledged that he did not complete or document a full investigation, did not submit 5‑day investigation summaries, and did not report either incident to the ombudsman or State Survey Agency. The DON stated that the water‑throwing incident met the definition of resident‑to‑resident abuse and that policy required reporting within two hours, but she and the Administrator did not report it externally because they believed the incident might not have occurred. The facility’s written abuse policy required immediate reporting of suspected abuse to the Administrator and specified agencies, and mandated thorough, documented investigations, which were not carried out or reported as required in either case.

The facility’s abuse policy, dated 2001, defined suspected abuse as requiring immediate reporting to the Administrator and to state licensing/certification, ombudsman, resident representative, law enforcement, and the resident’s physician, with “immediately” defined as within two hours for allegations involving abuse or serious bodily injury. The policy also required the Administrator to determine protective actions for residents and to ensure all allegations were thoroughly investigated, including review of documentation and evidence, review of the resident’s medical record and status, observation of the alleged victim, and interviews with the reporter, witnesses, the resident or representative, staff on all shifts, and the roommate, with complete documentation of the investigation. In both the kicking and water‑throwing incidents, staff at the point of care recognized the events as potential resident‑to‑resident abuse and reported them up the chain, but the Administrator and DON did not ensure that the required investigations, documentation, and external reports, including 5‑day summaries to the State Survey Agency, were completed in accordance with facility policy and regulatory expectations.