Failure to Timely Report Resident-to-Resident Altercation to Administrator and CDPH
Penalty
Summary
The facility failed to timely report a resident-to-resident altercation involving two residents to the Abuse Coordinator/Administrator and to the California Department of Public Health (CDPH). One resident, with diagnoses including anxiety disorder and dementia but assessed on the MDS as having no cognitive impairments and being independent with oral hygiene and dressing, initiated a physical altercation without provocation and attempted to strike another resident. The second resident, with diagnoses including COPD and CHF, was also assessed on the MDS as having no cognitive impairments and being independent with ADLs. A Change of Condition assessment documented that staff observed the first resident displaying verbal and physical aggression and initiating the altercation, and that both residents were separated to minimize escalation. The RN on duty at the time of the incident acknowledged in interview that she did not report the altercation to the Administrator, who is the facility’s Abuse Coordinator, and did not recall reporting the incident to CDPH, despite stating she was required to report such altercations to the Administrator and CDPH right away for resident safety. The Administrator stated she was not aware of the altercation until a later survey interview and confirmed that the RN should have reported the incident to her immediately, or to the DON if she was unavailable. Review of facility policies on abuse, neglect, exploitation, and misappropriation showed that suspected resident abuse was to be reported to the Administrator immediately and to the state licensing/certification agency immediately or within two hours, and that the facility was to report any allegations of abuse within the timeframes required by federal requirements. These policies were not followed in this incident, resulting in a delay in investigation by the Abuse Coordinator and CDPH and a potential for further abuse.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.