Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of abuse within mandated timeframes and to report the results of its investigation to the State Survey Agency. A resident with Parkinsonism and dementia, admitted on an unspecified date and discharged on 5/23/25, reported to the Social Services Manager (SSM) on 12/20/24, before 5:00 PM, that an RN, a hospital aide, and an LVN physically and verbally abused him. The resident alleged he was intimidated, dragged from bed, given medications late, had laxatives shoved into his mouth, and was hosed down in the shower with soap put in his eyes. The resident also alleged that an LVN withheld his medications and made him suffer. Facility documents titled “Report of Suspected Dependent Adult/Elder Abuse” (Reports 1, 2, and 3), dated 12/21/24, reflected these allegations, but one report did not include the date and time the allegation was reported, and indicated the LVN was placed on leave effective 12/20/24. The SSM stated she reported the resident’s allegations to CDPH, the Ombudsman, and local police on 12/21/24, and fax transmittal records showed these notifications occurred at 3:00 PM on 12/21/24, approximately 22 hours after the allegation was made. The Director of Staff Development stated that allegations involving physical harm or serious bodily injury must be reported immediately, but not later than two hours, and other forms of abuse must be reported to CDPH and other agencies within 24 hours. The Chief Human Resources Officer stated that the Human Resources Office began its investigation the day after the report and concluded it on 1/10/25, and also stated that their department does not report to external agencies. The Chief Nursing Officer confirmed that reporting to CDPH is not an HR function and that the result of the investigation was not reported to CDPH. The facility’s abuse policy referenced federal and state reporting requirements and immediate reporting of alleged mistreatment, neglect, or abuse, and an appendix quick guide required abuse and serious bodily injury to be reported immediately but not later than two hours to CDPH, local police, and the Ombudsman; however, the policy did not include reporting the results of all investigations of abuse allegations to CDPH within five working days.
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