F0610

D

Failure to Recognize and Report Resident Allegation of Neglect

San Mateo, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Facility staff failed to recognize and report an allegation of neglect when a resident stated she had been in pain and that staff did not respond to her calls for assistance over several hours. The resident reported that sometime in January she was very sick and in pain, repeatedly rang for the nurse, and no one came to her room. She stated that someone had closed her room door and that her call bell was not connected, which she did not initially realize. She continued to ring without response, became worried, and ultimately called the hospital emergency room herself. When ambulance staff arrived and wheeled her out of the room, she observed a LVN sitting at the desk and told the LVN she had been calling for hours for help, describing the experience as very scary.

Record review showed that the resident’s hospital discharge summary dated 1/15/2026 documented a diagnosis of recurrent acute diverticulitis, a sudden onset inflammation/infection of a portion of the colon that may cause sudden intense abdominal pain. During interviews, the LVN and the Unit Supervisor both acknowledged they were aware that the resident had alleged she was in pain and that staff did not respond to her calls for assistance. The DON stated that when the Unit Supervisor spoke with the resident by phone regarding her hospitalization on 1/21/2026, the Unit Supervisor did not identify the resident’s statements as an incident of neglect, instead characterizing them as the resident “just venting.” This response was inconsistent with the facility’s Abuse-Reporting & Investigations policy, which requires the facility to promptly report and thoroughly investigate all allegations of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, injuries of unknown source, and suspicions of crimes.