F0610

E

Incomplete Abuse Investigations Due to Missing Staff Interviews and Statements

Sylmar, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse investigation policy by not fully interviewing or obtaining written statements from all staff assigned to residents involved in alleged resident-to-resident physical abuse incidents. For Resident 1, who was admitted with encephalopathy, unspecified dementia, and generalized muscle weakness and had moderately impaired cognitive skills, a Change of Condition Evaluation (CIC) dated 2/15/2026 documented that Resident 1 received physical contact from Resident 2. RN 1 witnessed and separated the residents and completed a head-to-toe assessment with no pain or injuries noted. The Director of Staff Development (DSD) stated that on that date RN 1, LVN 2, and CNA 2 were assigned to Resident 1. The Director of Nursing (DON) reviewed the facility’s staff interview document dated 2/15/2026 and confirmed that it contained statements from RN 1, two clinical students, and one clinical instructor, but there were no statements from LVN 2 or CNA 2, despite their assignment to Resident 1.

For Resident 2, who was admitted with ESRD, COPD, and hypertension, the MDS and History and Physical indicated intact cognitive skills and capacity to understand and make decisions. A CIC dated 2/15/2026 documented that RN 1 witnessed Resident 2 make physical contact with Resident 1, separated them, and assessed Resident 2 with no pain or injury. The facility’s Five-Day Investigation Summary indicated that staff witness statements were reviewed. The DSD stated that on 2/15/2026, RN 1, LVN 1, and CNA 5 were assigned to Resident 2. However, upon review of the staff interview document dated 2/15/2026, the DON confirmed that only statements from RN 1, two clinical students, and one clinical instructor were present, and there were no statements from LVN 1 or CNA 5, even though they were assigned to Resident 2.

For Resident 3, admitted with acute kidney failure, difficulty in walking, and generalized weakness, the MDS and H&P indicated intact cognitive skills and decision-making capacity. A CIC dated 2/16/2026 documented that Resident 3 maneuvered an electric motorized wheelchair in the activity room, and the wheelchair made contact with Resident 4’s wheelchair, after which Resident 4 turned, extended an arm toward Resident 3, and made physical contact. Staff intervened, separated the residents, and assessed them with no visible injury and no pain reported. CNA 4 stated she was assigned to Resident 3 and was with another resident when the incident occurred. LVN 3 stated she was informed that her resident (Resident 3) hit Resident 4 in the right shoulder. The DSD stated that RN 1, LVN 3, and CNA 4 were assigned to Resident 3 on 2/16/2026. The DON reviewed the staff interview document and confirmed it contained a statement from LVN 3 but no statement from CNA 4, despite her assignment to Resident 3.

For Resident 4, admitted with acute embolism and thrombosis of a deep vein of the left lower extremity and hypertension, the H&P indicated capacity to understand and make decisions. A CIC dated 2/16/2026 documented that Resident 4 extended an arm toward Resident 3 and made physical contact, and that Resident 3 hit Resident 4’s left knee on the table. RN 1 offered pain medication, which Resident 4 refused, and assessed Resident 4 with no visible injuries. LVN 4 stated he was assigned to Resident 4 but was not in the activity room when the incident occurred and that RN 1 informed him of the incident; he stated he checked Resident 4 and found no pain or injury. The Activity Director reported that Activity Staff 1 observed Resident 4’s wheelchair bump into Resident 3’s wheelchair in the activity room. The DSD stated that RN 1, LVN 4, and CNA 3 were assigned to Resident 4 on 2/16/2026. The DON reviewed the staff interview document and confirmed that no staff statements were documented for this incident and specifically that there were no statements from LVN 4 or CNA 3.

Review of the facility’s policy and procedure titled “Abuse Investigation and Reporting,” last reviewed 4/2025, showed that the individual conducting the investigation must, at a minimum, interview staff members on all shifts who had contact with the residents during the period of the alleged incident, interview roommates, family members, and visitors, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further states that witness statements are to be obtained in writing, signed, and dated, either written by the witness or obtained by the investigator. The DON stated that, based on this policy, the investigations were not complete. The Administrator stated that for the allegations on 2/15/2026 and 2/16/2026, she interviewed RN 1 and Activity Staff 1 but did not interview the assigned staff for the involved residents, and acknowledged that the investigations for Residents 1, 2, 3, and 4 were incomplete.