F0610

D

Failure to Investigate and Report 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 thoroughly investigate and report two separate allegations of resident-to-resident abuse involving four residents. In the first incident, one resident with moderate cognitive impairment and a history of right tibia fracture and alcohol dependence reported to the Social Services Assistant (SSA) that, about a week earlier, his roommate had threatened him over television volume. He stated that the roommate told him that if he did not lower the TV, he would be hit, and that he responded by kicking the roommate in the lower torso. The SSA documented that the resident admitted to kicking his roommate and that she would notify administration and the DON. The SSA later struck this note from the EMR at the DON’s direction and replaced it with a handwritten paper note that removed the admission of kicking and stated only that there were disagreements over the TV and that the resident felt unsafe. No follow-up, investigation, or IDT documentation regarding this alleged abuse was found in the EMR.

The roommate, who had intact cognition and used a wheelchair and walker, later reported that a few weeks earlier his former roommate had kicked him, causing him to fall back into his wheelchair and sustain a bruise on his lower back from the wheelchair brake lever. A nurse’s note documented that this resident had reported a fall in his room on a prior date, with a reddish discoloration on his back consistent with his description. Multiple staff, including the Quality Nurse (QN), Charge Nurse (CRN) 2, the ADON, and the Administrator (ADM), confirmed that the facility’s process for alleged resident-to-resident abuse required immediate separation of residents, head-to-toe assessments, notification of the ADM as abuse coordinator, and timely reporting to the MD, responsible party, police, ombudsman, and state agency, along with thorough investigation and documentation. The QN, CRN 2, ADON, and ADM all acknowledged that no investigation, reporting, or 5‑day summary was completed for this incident, and the DON stated she did not investigate because she believed it was only words, thought the incident was old and the alleged aggressor had been discharged, and asked the SSA to strike the original note because it appeared to show abuse that was not reported.

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 stated that they had showered and dressed this resident in dry clothing earlier that day and later found him soaked, and the resident told them that “the man in the wheelchair” had thrown water on him. Both CNAs and CRN 1 identified this as resident-to-resident abuse and reported it to the DON and ADM, with CRN 1 also texting the IDT, including the ADM and DON, that the resident had water thrown on him by another resident. A nursing note documented that the resident claimed someone threw water on him but could not recall the face, and another note for the suspected aggressor described prior verbal aggression, threatening behavior, and staff concern that he might throw water or harm his roommate if disturbed by noise. The ADM stated he interviewed both residents, offered room changes (which were refused), did not document his investigation in the EMR, did not complete full investigations or 5‑day summaries, and did not report to the ombudsman or other authorities. The DON acknowledged that having water thrown on a resident by another resident was abuse, that the ADM had spoken with the residents, and that the incident was not reported to authorities because she believed it did not happen, despite facility policy requiring immediate reporting and thorough investigation of all abuse allegations.

The facility’s written policy on Abuse, Neglect, Exploitation or Misappropriation–Reporting and Investigating required that any suspicion of resident abuse be reported immediately to the administrator and appropriate authorities, defined “immediately” as within two hours for allegations involving abuse or serious bodily injury, and mandated that all allegations be thoroughly investigated by the administrator. The policy specified that the investigation must include review of documentation and evidence, review of the resident’s medical record, observation of the alleged victim, and interviews with the reporter, witnesses, the resident or representative, staff on all shifts, and the roommate, with complete and thorough documentation. In both incidents—resident kicking a roommate and a resident having water thrown on him—staff recognized the events as resident-to-resident abuse and reported them up the chain, but the ADM, as abuse coordinator, did not complete or document full investigations, did not submit required 5‑day summaries, and did not report the allegations to external authorities as required by policy and state law. The DON acknowledged responsibility as DON, admitted that the incidents were considered resident-to-resident abuse, and confirmed that the facility did not follow its own abuse reporting and investigation procedures for these allegations.