FRESNO, CA - A mental health worker at Horizon Health & Subacute Center physically pushed a resident after being pushed first during a bathroom incident, according to a federal inspection report that also found the facility failed to submit a required follow-up investigation to state authorities.
Physical Altercation in Resident Bathroom
The incident occurred on June 24, 2024, between 5:00 PM and 5:15 PM when a resident was found yelling in his bathroom. A mental health worker attempted to de-escalate the situation, but the resident pushed the staff member. The mental health worker responded by pushing the resident with both hands on each shoulder, causing the resident to stumble backward.
The facility reported the incident to the California Department of Public Health through a SOC341 form - Report of Suspected Dependent Adult/Elder Abuse. However, federal inspectors discovered during their July 9, 2024 complaint investigation that the facility had not completed the required follow-up documentation.
Missing Required Investigation Report
When inspectors interviewed the facility Administrator on July 9, 2024, the Administrator acknowledged that "We don't have a 5-day follow up report." This admission revealed the facility's failure to comply with federal regulations requiring comprehensive investigation documentation.
Federal nursing home regulations mandate that facilities conduct thorough investigations of all alleged abuse incidents and provide detailed reports to appropriate authorities. The missing documentation represents a significant compliance failure that could impact resident safety oversight.
Facility Policy Requirements Not Met
According to the facility's own policy titled "Reporting of Alleged Violations," dated March 2018, the facility must provide "A completed copy of all investigation findings, documentation forms and written statements from witnesses, for all allegations of abuse" to the Administrator and "to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident."
The policy further states that "if the alleged violation is verified appropriate corrective action must be taken." The facility's failure to complete this investigation within the required timeframe indicates a breakdown in their internal reporting and oversight systems.
Understanding Physical Intervention Protocols
Nursing homes are required to maintain strict protocols regarding physical interventions with residents. Staff members receive specialized training in de-escalation techniques designed to prevent physical confrontations. When residents become agitated or aggressive, trained personnel should use verbal calming methods, environmental modifications, and if necessary, seek assistance from additional staff members.
Physical contact should only occur when absolutely necessary to prevent immediate harm to the resident or others, and must follow specific techniques that minimize risk of injury. Pushing a resident, particularly in a bathroom setting where fall risks are elevated, violates standard care protocols and creates serious safety concerns.
Bathroom Safety Considerations
The bathroom setting of this incident raises additional safety concerns. Bathrooms present multiple fall hazards including hard surfaces, wet floors, and limited maneuvering space. When a resident stumbles backward in such an environment, the risk of serious injury including head trauma, hip fractures, or other fall-related injuries increases significantly.
Residents in nursing homes often have conditions that affect balance, mobility, and bone density, making them particularly vulnerable to fall-related injuries. Medical conditions common in nursing home populations, such as osteoporosis, medication effects, and cognitive impairments, can increase both fall risk and injury severity.
Regulatory Reporting Requirements
Federal regulations require nursing homes to report incidents of suspected abuse to multiple authorities within specific timeframes. The initial SOC341 report represents just the first step in a comprehensive investigation process designed to protect resident safety and ensure accountability.
The 5-day follow-up report serves a critical function by providing detailed investigation findings, witness statements, and corrective actions taken. This documentation allows state survey agencies to assess whether facilities are properly investigating incidents and implementing appropriate measures to prevent future occurrences.
Investigation and Documentation Standards
Proper incident investigations in nursing homes must include interviews with all involved parties, review of relevant policies and procedures, examination of staff training records, and development of corrective action plans. The investigation should determine whether policies were followed, if additional training is needed, and what systemic changes might prevent similar incidents.
Documentation requirements exist to ensure transparency and accountability in the nursing home industry. When facilities fail to complete required reports, it undermines the regulatory system designed to protect vulnerable residents and can indicate broader problems with facility oversight and management.
Impact on Resident Care Quality
The combination of a physical altercation between staff and resident, followed by inadequate investigation and reporting, suggests potential deficiencies in staff training, incident management, and administrative oversight at Horizon Health & Subacute Center. These issues can impact overall care quality and resident safety.
Residents and families rely on nursing homes to maintain professional standards that protect physical safety and dignity. When staff members respond inappropriately to challenging situations, it can erode trust and potentially indicate broader training or supervision deficiencies.
Facility Response and Next Steps
The inspection findings will require Horizon Health & Subacute Center to develop and implement corrective actions addressing both the initial incident and the reporting failure. The facility must demonstrate that appropriate measures have been taken to prevent similar occurrences and ensure compliance with federal reporting requirements.
State survey agencies will monitor the facility's corrective actions and may conduct follow-up inspections to verify compliance. The facility's response to these findings will be critical in demonstrating their commitment to resident safety and regulatory compliance.
The complete inspection report and facility response documents are available through the Centers for Medicare & Medicaid Services Nursing Home Compare website, providing transparency for current and prospective residents and their families making care decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Horizon Health & Subacute Center from 2024-07-09 including all violations, facility responses, and corrective action plans.
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