Failure to Investigate Delayed ER Transfer After Physician Order and Resident Death
Summary
The deficiency involves the facility’s failure to thoroughly investigate an unexpected resident death and to rule out neglect after a physician’s order for immediate transfer to the ER was not followed. A resident with systolic congestive heart failure, atrial fibrillation, and hypertension had a recent MDS showing a BIMS score of 11, indicating moderate cognitive impairment. On the morning in question, nursing documentation showed the resident had loose, foul-smelling dark stools and was encouraged to increase oral hydration, with SpO2 at 95% on 2 L O2 via nasal cannula. At 8:54 AM, the resident’s BP was documented at 73/47 mm Hg, well below normal. A physician progress note, entered later as a late entry, recorded that at 9:33 AM the physician gave a verbal order to nursing (to the ADON) to send the resident to the ER due to low BP. Subsequent nursing notes documented that during morning rounds the resident was awake, responsive but disoriented, with BP 71/47, HR 64, temp 97.7°F, RR 18, and SpO2 95% on 2 L O2. Nursing staff notified the ADON, who ordered STAT labs, X‑ray, and urinalysis and indicated she would contact the physician. A provider progress note by the ADON, entered as a late entry, stated that she was initially unable to reach the physician, that the DON was immediately notified, and that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated. However, the facility’s order audit report showed a telephone order at 9:20 AM to send the resident to the ER for emergency transfer due to change in condition, contradicting the ADON’s late entry note about the timing and sequence of events. The physician later stated she had instructed the ADON around 9:30 AM to call 911 and send the resident to the ER and that she assumed the resident had already left when she arrived for rounds at 10:00 AM. Interviews with staff revealed conflicting accounts and suggested a delay in carrying out the physician’s order to transfer the resident. The physician reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a BP of 64/34 mm Hg and that staff told her they were told to wait until she came in. The physician stated that the ADON told her they were waiting for labs to be drawn before calling 911, which the physician considered inappropriate for the resident’s condition. Nursing notes documented that when the physician arrived, the resident’s BP was 63/36, SpO2 could not be obtained, and the physician again ordered transfer to the ER, after which 911 was called and the resident was transported and later expired in the hospital that day. The DON stated she was not made aware of the situation until after the resident’s death, despite the ADON’s late entry note claiming the DON had been notified, and that the ADON resigned after writing the back‑dated note. The administrator provided an undated, untitled, one‑page “investigation” summary and conclusion with no resident name, incident date, or attached statements, which did not reflect the detailed events, conflicting timelines, or staff interviews described elsewhere in the record. This minimal document did not meet the facility’s own Abuse Investigation and Reporting and Reportable Events policies, which require prompt, thorough investigations, interviews, medical record review, and root cause analysis for serious events. The facility’s policies required that all reports of suspected neglect and serious reportable events be promptly identified, thoroughly investigated, and documented, including interviews of involved staff and witnesses, review of the medical record and care plans, evaluation of contributing factors, and root cause analysis for serious events. The DON reported that corporate was made aware and conducted an investigation but that she herself was not interviewed. The administrator acknowledged there appeared to have been a delay in sending the resident to the ER and attributed the situation in part to interpersonal conflict between two ADONs. The only investigation document produced consisted of a brief, generic summary and conclusion describing hypotension with stable heart rate and oxygen saturation, ongoing monitoring, physician communication, and eventual transfer to the ER, without specific identification of the resident, the date, the sequence of orders and actions, or any analysis of the delay or conflicting documentation. As a result, the surveyors determined that the facility failed to thoroughly investigate the unexpected death and the apparent failure to promptly follow a physician’s order for emergency transfer, and therefore failed to rule out neglect as required by facility policy and regulation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to identify and thoroughly investigate multiple grievances alleging verbal abuse, rude and unprofessional comments, and threats of involuntary seclusion by an RN and an LPN toward several residents. The record shows repeated complaints that staff yelled at residents, blocked a resident from entering his room, and used a “time-out” approach, but the facility often interviewed only the directly involved parties, left grievance sections blank, did not document timely reporting to the administrator and SA, and did not remove the staff from direct care pending investigation.
Incomplete investigation of alleged resident property misappropriation: A resident with intact cognition and diagnoses including bipolar disorder, anxiety, and intellectual disability reported that the cord to a personal refrigerator had been cut. Staff notes reflected conflicting statements about who may have damaged it, but the NHA and DON could not explain how it happened or who was responsible until surveyor inquiry. The facility could not produce documentation of a full investigation, including statements from the resident and Maintenance Director, witness interviews, staff assignment review, a written summary, or investigative findings.
Failure to investigate resident-on-resident abuse and unexplained perineal injury: A cognitively intact resident reported being frightened after another resident repeatedly entered her room, grabbed belongings, and snarled at her, but leadership did not complete a formal abuse investigation. The facility also did not investigate a cognitively intact resident’s unexplained labial/perineal tear after an ER visit, despite the injury being documented as a laceration of the perineum and staff acknowledging the concern was discussed but not reported or investigated.
Failure to investigate alleged mistreatment during grooming: A resident with dementia, depression, and severe cognitive impairment was dependent on staff for grooming and hygiene. After a mat of hair was removed, the resident’s scalp was noted to be red and irritated, and staff later reported the resident was in pain after the hair was brushed out. The facility handled the issue as a grievance, but there was no documentation of a thorough abuse/mistreatment investigation, and the administrator later stated it should have been investigated as an abuse allegation.
Failure to Investigate Allegation of Resident Property Misappropriation: A resident with severe major depressive disorder with psychotic symptoms and a cognitive communication deficit had money taken from a bank account, which was reported by the EC to the DON. The DON notified the ADM and police investigated, but the facility did not conduct its own abuse investigation, and the ADM confirmed no written investigation summary was completed or submitted to CDPH.
Failure to Investigate Reported Falls: A resident with intact cognition had two reported fall incidents, including an unwitnessed fall and a fall reported after returning from home, but neither incident was entered on the incident log. Staff and the DON stated that self-reported falls should be assessed and investigated to determine reporting needs, root cause, and whether abuse or neglect occurred, but the facility did not investigate the later fall and could not rule out abuse or neglect.
Failure to Investigate Abuse and Verbal Abuse Grievances
Penalty
Summary
The facility failed to identify allegations of verbal abuse and threats of involuntary seclusion that were reported through grievances involving multiple residents and two nurses. The report describes grievances and interviews involving an RN and an LPN, including concerns that the LPN made rude and unprofessional comments to a resident and the resident’s representative, and that the RN yelled at residents, used a harsh tone, blocked a resident from entering his room, and told residents they were going into a “time-out.” The grievances also described residents becoming upset, feeling inadequate, refusing meals, and reporting that staff were scolding them for self-transferring or attempting to enter their rooms. The facility did not complete timely and thorough investigations of these concerns. In several instances, only the directly involved resident or representative was interviewed, with no documentation of broader interviews with other residents, witnesses, or staff who may have had knowledge of the events. The report notes missing or blank sections on grievance forms, including resolution and follow-up, and no documented assessment of whether residents felt safe or experienced psychosocial effects after the incidents. One grievance involving the LPN was signed off by the DON, but the administrator did not sign off until months later. Another grievance involving the RN was not reported to the administrator and State agency immediately as an allegation of verbal abuse, and the report states there was no documented re-education about what constitutes verbal abuse or timely reporting requirements. The facility also failed to immediately remove the RN and LPN from direct care pending investigation, despite its policy stating that allegations of employee-to-resident abuse required immediate reporting and suspension pending investigation. The report identifies a pattern of recurring complaints about the RN across multiple residents, including reports from staff that the RN was bossy, yelled at residents, blocked a resident from his room, and upset residents who were attempting to self-transfer. The administrator and regional clinical service director acknowledged that the grievance forms lacked thorough investigation and follow-up, and that additional interviews should have been completed, but the report documents that these deficiencies had already occurred across multiple grievances involving six residents.
Incomplete investigation of alleged resident property misappropriation
Penalty
Summary
The facility failed to conduct a thorough internal investigation after receiving an allegation of possible misappropriation of resident property involving a resident who was cognitively intact with a BIMS score of 15 and had diagnoses including bipolar disorder, anxiety, and intellectual disability. The facility’s Abuse Policy required allegations of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source to be promptly reported and thoroughly investigated by the administrator and/or designee, with investigations including all reports and allegations of abuse. A nurse’s progress note documented that the resident reported someone had entered the room and cut the electrical cord to the resident’s personal refrigerator, which had been cut in two places. The resident stated someone should be held responsible and said the resident intended to contact law enforcement and a family member. Another note documented the resident later alleged a housekeeper cut the cord, while staff documented housekeeping did not work during the time identified by the resident. During surveyor interview, the resident stated someone had cut the cord but did not know who damaged it or how it occurred, and the refrigerator remained in the room with the cord cut and not operational. The Nursing Home Administrator and DON confirmed they did not know how the cord was cut, who cut it, why it was cut, or where the severed portion was until surveyor inquiry prompted additional discussion. The Maintenance Director stated he had responded to the issue, restored electrical service, spoke with the resident, and later found the severed portion of the cord concealed in the resident’s room. The facility could not provide documentation showing it obtained a statement from the resident or Maintenance Director, identified and interviewed all relevant witnesses, reviewed staff assignments or other investigative information, completed a written investigative summary, or documented investigative findings or a conclusion regarding the allegation.
Failure to investigate resident-on-resident abuse and unexplained perineal injury
Penalty
Summary
The facility failed to conduct a formal investigation into an allegation of resident-on-resident mental abuse involving a cognitively intact resident who reported being frightened by another resident entering her room repeatedly. The resident stated the other resident had come into her room multiple times, grabbed belongings, snarled at her, and left her scared. Progress notes also documented that she placed a walker in front of her door on two nights to barricade the other resident from entering and stated, "I'm scared to death of him." The resident involved in the behavior had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease, and was documented as pacing, wandering daily, and significantly disrupting the care or living environment of other residents. Staff interviews showed the concern was reported to nursing leadership, but no management member came in that weekend to start an investigation. An LPN stated the DON was notified of the resident-on-resident altercation and that the facility process was for administration to be notified and management to perform investigations when allegations of physical, sexual, or mental abuse were reported. The DON stated she was aware of the situation but was unsure whether any investigation had been completed. The administrator stated a VA had not been filed because the facility did not feel the concern reached the level of potential abuse, and the issue was only discussed in the IDT. The IDT notes for that week were requested but not provided. The facility also failed to investigate a possible sexual abuse or injury of unknown origin when a cognitively intact resident with multiple medical conditions, including ulcerative colitis, cirrhosis of the liver, depression, hypothyroidism, hypertension, edema, osteoarthritis, and a history of malignant neoplasm of the uterus, was found to have an unexplained perineal laceration. The resident was frequently incontinent and required substantial to maximum assistance with ADLs and peri care. The ER record identified a very minor labial tear/abrasion with minimal blood present and listed laceration of the perineum, while the facility note documented that the resident denied being abused when asked. Staff stated they were only told to be more gentle with cares, and several staff reported they had not received specific education about peri care for the resident after the ER visit. The DON and administrator stated they did not report or investigate the injury because they believed it was not reportable, despite acknowledging that abuse, neglect, and injuries of unknown origin should be reported and investigated.
Failure to Investigate Alleged Mistreatment During Hair Grooming
Penalty
Summary
The facility failed to ensure an alleged mistreatment during grooming and hygiene was thoroughly investigated for Resident #35. The resident had diagnoses of dementia and depression, and a quarterly assessment dated 10/31/25 showed a BIMS score of 3, indicating severe cognitive impairment. The assessment also showed the resident was dependent on staff for grooming and hygiene. A Concern/Grievance Report dated 11/19/25 documented that a mat of hair was removed from the back of the resident’s head and a reddened area was noted afterward, and a nurse’s progress note from the same day stated the resident’s scalp was red and irritated and that the resident did not want to get up. A review of the facility’s abuse and mistreatment investigations from 07/01/25 through 07/02/26 showed no documentation that the allegation of mistreatment related to brushing out the resident’s matted hair was investigated. During interviews, an LPN stated the allegation of mistreatment involved Resident #35 being mistreated while their matted hair was brushed and said the allegation was investigated, while the administrator stated the issue had been completed as a grievance and was caused by the matting of the hair and removing it. A CNA stated the resident often refused care, had a mat in their hair, and was hollering in pain the next morning after someone brushed it out. The administrator later stated the matter should have been investigated like an abuse allegation.
Failure to Investigate Allegation of Resident Property Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of resident property involving one resident who was admitted with severe major depressive disorder with psychotic symptoms and a cognitive communication deficit. The resident’s Emergency Contact notified the DON that money had been taken from the resident’s bank account, and the DON reported the event to the Administrator, who called the police. The DON stated that police came to the facility to investigate the allegation, but the facility did not conduct its own investigation of the abuse allegation. During interview, the Administrator confirmed he was the facility’s Abuse Coordinator and stated the investigation was conducted by police. He also confirmed that an investigation summary was not written and was not submitted to CDPH. The facility’s policy required the Administrator or designated representative to initiate an investigation immediately, interview individuals with relevant information, and provide a written report of the results of all abuse investigations to CDPH within five working days; however, no facility investigation summary was provided.
Failure to Investigate Reported Falls
Penalty
Summary
The facility failed to conduct a thorough investigation for one resident who had two reported fall incidents. Review of the facility’s policy showed that all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are to be reported and thoroughly investigated by facility management, with findings documented and reported. The Nursing Home Guidelines also stated that all incidents require thorough investigation and reporting as necessary, and that investigations are intended to determine whether abuse or neglect occurred and how to prevent further occurrences. Resident 1 was admitted to the facility and had intact cognition on the admission MDS. A review of records showed an investigation report for an unwitnessed fall reported by the resident and collateral contact, and a progress note showing the resident left the facility with the collateral contact and later returned with a report that the resident had fallen at home. However, the June and July 2026 incident logs contained no entries for either fall incident. Staff stated that self-reported falls should be investigated, assessed, and documented, and the DON stated the purpose of an incident investigation was to determine reporting requirements, identify root cause, maintain resident safety, and rule out abuse or neglect. The DON also stated the facility was unaware of the fall reported on 07/17/2026 and that it should have been investigated, and acknowledged that abuse or neglect could not be ruled out because the incident was not investigated.
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