F0610

D

Failure to Investigate and Timely Report Resident-to-Resident Abuse Allegations

Norwalk, California Survey Completed on 03-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to treat resident-to-resident physical and sexual assault allegations as abuse, to conduct thorough investigations, and to report results to the State Survey Agency within required timeframes. One resident with schizophrenia (Resident 2) alleged that another resident (Resident 1) tried to have sex with him, and also admitted to punching that resident in the face. Interdisciplinary notes dated 2/7/2026 documented that Resident 1 sustained a 1.2 cm laceration to the right upper eyebrow requiring medical attention after being punched by Resident 2. Standards Compliance Supervising RN confirmed that these incidents were not considered abuse by the facility because they involved resident-to-resident physical and sexual assault, and therefore were not reported to the California Department of Public Health (CDPH) within 2 hours; instead, they were reported three days later.

The facility did not conduct a thorough investigation into the alleged sexual assault. RN 2 stated he interviewed Resident 2, who reported he hit Resident 1 because he was trying to have sex with me, but RN 2 did not ask any further questions. The Program Director reported that after speaking with nursing staff and the treatment team, they concluded there was no validity to the sexual assault allegation and determined it was a delusion, and therefore did not investigate it as abuse or complete a SOC 341 suspected abuse report. Resident 2’s medical record did not contain a physician report following the sexual assault allegation, and the temporarily assigned psychiatrist did not see or evaluate Resident 2 until three days after the incident and did not address the allegation. The on-call psychiatrist on the date of the incident did not go to the unit to evaluate Resident 2 after the allegation, and the Patients’ Rights Advocate was not notified of the allegation.

The facility also failed to investigate the physical assault on Resident 1 as abuse and to follow its own abuse reporting policies. Resident 1, who had multiple complex medical conditions including absence of the left eye, a tracheostomy, a gastrostomy tube, need for assistance, difficulty communicating needs, and use of a wheelchair for ambulation, was punched in the face by Resident 2 while sleeping, resulting in a laceration requiring medical attention. The Program Director stated that resident-on-resident physical assault was not considered abuse and that only staff could be perpetrators, so the incident was not investigated as abuse and a SOC 341 was not completed. The psychiatrist who saw Resident 1 four days after the incident focused only on medical issues related to the tracheostomy and did not address the physical assault. The Patients’ Rights Advocate was not notified of the physical assault, and the on-call psychiatrist did not evaluate either resident after being informed of the incident. These actions and inactions occurred despite facility policies defining physical abuse as including assault and requiring immediate completion of SOC 341, protection and counseling for the resident, notification of the Patients’ Rights Advocate, immediate reporting of alleged abuse to CDPH within 2 hours, and submission of investigation results to CDPH within 5 working days.

The facility’s written policies on rape or sexual assault of elder/dependent adults and on reporting patient abuse and neglect required immediate medical attention, supportive counseling, evidence gathering, completion of SOC 341, physician reporting, and prompt reporting to CDPH for all alleged abuse, including in skilled nursing units. The policies also required that all alleged violations involving abuse be reported immediately but not later than 2 hours if the events involved abuse, and that results of investigations or follow-up reports be submitted to CDPH within 5 working days. In the incidents involving Residents 1 and 2, the facility did not follow these policies: alleged sexual assault and physical assault were not treated as abuse, SOC 341 forms were not completed, the Patients’ Rights Advocate was not notified, physician evaluations and reports were delayed or omitted, and the results of investigations were not submitted to the State Survey Agency within 5 working days because investigations were not conducted.