Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify and report resident-to-resident physical and sexual abuse allegations within the required timeframe for three separate incidents. In the first incident, one resident punched another in the face, causing a laceration above the right eyebrow, after alleging that the other resident attempted to engage in unwanted sexual activity. The Standards Compliance Supervising RN confirmed the incident and the sexual assault allegation but stated that the department of standards and compliance was not open over the weekend and that she did not consider resident-on-resident physical and/or sexual assault as abuse, so it was not reported within 2 hours. The facility’s own policy, however, defined abuse of a dependent adult/elder to include physical abuse and sexual assault and required all alleged violations involving abuse in skilled nursing units to be reported to CDPH immediately, but not later than 2 hours after the allegation. The Patients’ Rights Advocate (PRA) also reported not receiving any notification of physical and/or sexual assault or abuse related to this incident. In the second incident, one resident kicked another in the buttocks without provocation, and the second resident retaliated by punching the first resident in the face three times. The Standards Compliance Director confirmed that this physical altercation was not reported to CDPH until two days after it occurred, despite the policy requiring reporting within 2 hours, and the PRA stated he had not received any notification of physical abuse for either resident. In the third incident, a resident allegedly punched another resident in the chin following a verbal altercation; the Standards Compliance Director again confirmed that this allegation was not reported to CDPH until two days after the incident, and the PRA reported no notification of this physical abuse allegation. Across all three events, the facility did not follow its policy requiring immediate, but no later than 2-hour, reporting of all alleged abuse to CDPH and failed to notify the PRA of the allegations.
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