Failure to Timely and Separately Report Allegations of Verbal and Medication-Related Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey Agency within 2 hours as required by state law and the facility’s Abuse Prevention and Management policy. The policy required the Administrator or designee to notify law enforcement immediately or within 2 hours of an initial report and to send a written report to the Ombudsman, law enforcement, and CDPH within 2 hours. On 2/25/26 at approximately 3:45 p.m., a CNA reported that the resident’s responsible party told the resident she was an addict and that she would contact the physician to have the resident’s pain medication discontinued. This allegation was reported to CDPH at 7:19 p.m., more than three and a half hours after the incident, exceeding the 2-hour reporting requirement. In addition, the Director of Rehabilitation documented that an allegation of abuse was reported to her on 2/25/26 at 4:30 p.m. after she witnessed the responsible party yelling at the resident on the telephone. The resident told the DOR she was concerned that, upon discharge home with the responsible party, her pain medications would be thrown away and stated that the responsible party had mental health issues. The DOR reported her concerns to the Administrator and was instructed to write a statement to be submitted with a similar allegation of abuse. The Administrator stated she planned to combine two distinct allegations involving the same resident into a single report instead of reporting each allegation independently. Both the Administrator and the DOR acknowledged that each allegation must be reported separately and that, as mandated reporters, they did not follow the facility’s abuse reporting policy.
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