F0609

D

Failure to Timely Report and Act on Resident Abuse Allegation

Sylmar, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an allegation of staff-to-resident abuse to the Administrator, the State Survey Agency (CDPH), the Ombudsman, and local law enforcement within the required two-hour timeframe. The involved resident, identified as Resident 20, had multiple diagnoses including type 2 diabetes mellitus, legal blindness, and adult failure to thrive, and was assessed as having severely impaired cognition. According to the Minimum Data Set, the resident required extensive assistance with most activities of daily living. The History and Physical indicated that the resident had the capacity to understand and make decisions.

On the early morning in question, at approximately 4:30 a.m., Certified Nursing Assistant (CNA) 6 was providing ADL care to Resident 20 when the resident accused CNA 6 of hitting her during care and continued to scream and repeat the accusation. CNA 6 acknowledged that such an accusation should be considered an allegation of abuse but did not report it to the charge nurse because she believed she had not hit the resident. CNA 6 continued providing care, then left to care for another resident without notifying supervisory staff. CNA 5, who was caring for the resident’s roommate, later observed Resident 20 upset and crying and heard her state in Spanish that CNA 6 was very rough with her. CNA 5 then informed Licensed Vocational Nurse (LVN) 8 that the resident was upset and requested that LVN 8 speak with the resident.

LVN 8 went to the room, found Resident 20 upset, and heard the resident state that she had been hit by a CNA, but LVN 8 did not ask the resident to identify which CNA was involved. LVN 8 checked the resident for injuries, found none, and then resumed medication administration without reporting the allegation to the Administrator or Director of Nursing and without removing the alleged perpetrator from the assignment. Later that morning, the Assistant Director of Nursing (ADON) was informed by the nurse assigned to Resident 20 that the roommate reported hearing a slapping sound while Resident 20 was receiving care and that Resident 20 said she had been hit on the face by CNA 6. The ADON confirmed through interviews with CNA 5, CNA 6, and LVN 8 that the allegation occurred between approximately 4:30 a.m. and 5:00 a.m. The Administrator was not made aware of the allegation until about 9:15 a.m., at which time she learned that CNA 6 had not reported the allegation, CNA 5 had only reported to LVN 8, and LVN 8 had not escalated the allegation. The facility’s abuse policy required that any suspicion or allegation of abuse be reported immediately to the Administrator and to CDPH, the Ombudsman, and law enforcement within two hours, and that any employee accused of abuse be removed from resident contact until the investigation was complete; these requirements were not followed in this incident.

The Director of Staff Development, ADON, and Administrator each confirmed during interviews that all staff are mandated reporters and that any allegation of abuse, regardless of perceived validity, must be reported immediately to the Administrator so that external reporting can occur within two hours. They also confirmed that the accused staff member should be removed from the assignment and from resident contact pending investigation. In this case, CNA 6 did not report the allegation to the nurse, CNA 5 did not report directly to the Administrator, and LVN 8 did not notify the Administrator or remove CNA 6 from caring for the resident. As a result, the facility did not follow its own policy and regulatory requirements for timely reporting of an abuse allegation involving Resident 20.