Failure to Report Resident-to-Resident Physical Abuse Allegation to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the California Department of Public Health, the Ombudsman, and local law enforcement in accordance with its Abuse, Neglect, and Exploitation policy dated 12/19/2022. The policy required that all alleged violations involving abuse be reported immediately, but not later than two hours after the allegation is made, to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable. Despite this requirement, the facility did not report an incident in which one resident grabbed another resident’s arm in the hallway, which staff and leadership acknowledged should have been treated and reported as an allegation of physical abuse. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction, along with gait and mobility abnormalities, and required substantial to maximal assistance with most ADLs and was dependent on staff for transfers and walking. Resident 1’s H&P indicated capacity to understand and make decisions, and the MDS showed mild cognitive impairment. Progress notes dated the day after the incident documented that the Social Services Director (SSD) requested a psychology consultation because Resident 1 was having a hard time due to health challenges. During interview, Resident 1 stated being scared when another resident grabbed their left arm in the hallway. Resident 4, who grabbed Resident 1’s arm, had diagnoses including metabolic encephalopathy, psychosis, and schizophrenia, with the H&P indicating a lack of capacity to understand and make decisions and the MDS showing severe cognitive impairment and need for substantial/maximal assistance with multiple ADLs. On the day of the incident, documentation and interviews indicated Resident 4 was agitated, yelling, throwing objects, grabbing others, and hitting their head against the wall, and was sent to an acute hospital for further evaluation. Multiple staff, including a PTA, CNA, SSD, LVN, DON, and the Administrator, confirmed that Resident 4 grabbed Resident 1’s arm, that this scared Resident 1, and that such unwanted grabbing should be reported as an allegation of physical abuse within two hours; the DON and Administrator acknowledged the facility did not report this incident to the required external agencies as mandated by policy.
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