LOS ANGELES, CA - A state inspection at Temple Park Convalescent Hospital revealed the facility failed to properly investigate and report multiple incidents involving residents, including a physical altercation between roommates and unexplained facial injuries on a cognitively impaired patient.
Physical Altercation Between Roommates Goes Unreported
On August 4, 2024, at approximately 10:59 pm, a resident reported being struck with a wooden stick by his roommate during a dispute over alleged theft. The incident began when Resident 4 discovered his debit card balance had decreased from $814 to $600 after ordering food with his roommate, Resident 3. According to facility documentation, Resident 4 stated that Resident 3 had photographed both sides of his debit card, including the security code, and asked for the address associated with the card.
When Resident 4 confronted his roommate about the missing funds, the situation escalated. Resident 3 reportedly became upset, used racial slurs, and threw ice from a cup at Resident 4. In response, Resident 4 struck Resident 3 on the arm with a wooden stick, causing a skin tear and discoloration. Resident 3 was able to move his right arm without difficulty, though visible injury was documented. Emergency services were called to the facility.
Despite the clear documentation of physical contact between residents resulting in injury, the facility failed to properly report the incident to required oversight agencies. Staff documented the skin tear and noted that Resident 3 denied pain or discomfort related to the injury. However, critical steps in the facility's own abuse prevention protocols were not followed.
Physical altercations between residents in nursing facilities require immediate investigation and reporting to protect all parties involved. When residents engage in physical contact that results in injury, facilities must determine whether this represents an isolated incident or a pattern that could place other residents at risk. The failure to investigate thoroughly can leave vulnerable residents exposed to repeated harm.
The incident was particularly concerning because both residents were cognitively intact and capable of consenting to their care. Resident 3 required partial to moderate assistance with activities of daily living, while Resident 4 had more significant physical limitations due to hemiplegia affecting his left side following a stroke. The combination of cognitive awareness and physical vulnerability creates a complex dynamic that requires careful assessment and appropriate interventions.
Unexplained Facial Injuries on Cognitively Impaired Resident
Two days after the roommate altercation, on August 6, 2024, at 11:50 pm, nursing staff discovered bruising on another resident during routine rounds. Resident 5 was found with skin discoloration under the left lower eye and left ear. The resident was unable to explain what had occurred due to confusion and dementia.
Resident 5 had been readmitted to the facility with diagnoses including metabolic encephalopathy, dementia, and difficulty swallowing. According to assessment records, this resident had severe cognitive impairments, lacked the capacity to consent to care decisions, and was completely dependent on staff for all activities of daily living. These factors made the resident particularly vulnerable and unable to protect himself or report concerns.
When observed by inspectors on August 12, 2024, Resident 5 was found sleeping and did not respond to a soft call or light touch. The bruising under the left eye extended from the outer to inner eye, measuring approximately 3.8 centimeters by 2.5 centimeters. The center of the bruise, about half a centimeter in size, was raised and dark purple in color. The surrounding area showed reddish-yellowing discoloration with a purple line extending from the inner eye to the middle of the under-eye area.
During the inspection, the Assistant Director of Nursing suggested the resident may have scratched himself or hit his head against the siderail, but acknowledged that no one had witnessed the events leading to the bruising. Significantly, the Assistant Director of Nursing admitted the bruise was not consistent with a scratch. Despite this admission, no investigation had been completed, and the incident was not reported to outside agencies including police, the Department of Public Health, or the Ombudsman.
Injuries of unknown origin in nursing home residents require immediate attention and investigation. When a resident cannot communicate how an injury occurred, facilities have a heightened responsibility to determine the cause and ensure it does not represent abuse or neglect. The pattern and severity of bruising can provide important clues about how an injury occurred. In this case, the raised center with dark purple coloration surrounded by reddish-yellowing discoloration suggests blunt force trauma rather than a minor bump or scratch.
The cognitive status of Resident 5 made proper investigation even more critical. Residents with dementia and severe cognitive impairment cannot advocate for themselves, making them particularly vulnerable to repeated harm. Without thorough investigation and appropriate interventions, such residents may experience ongoing injuries while staff remain unaware of the cause.
Failure to Follow Mandatory Reporting Requirements
The inspection revealed systematic failures in the facility's reporting obligations. For the physical altercation between Residents 3 and 4, there was no documented evidence that the incident was reported to the Ombudsman or the Department of Public Health. Additionally, the facility failed to conduct required 72-hour monitoring, during which social work staff should have visited the residents daily to ensure their emotional and mental well-being.
The Assistant Administrator acknowledged during the inspection that Resident 5's facial bruising should have been classified as an injury of unknown origin because the resident was confused, unable to verbalize what happened, and no one witnessed the event. The Assistant Administrator confirmed that injuries of unknown origin must be investigated to prevent further harm and reported to the Ombudsman, police, and Department of Public Health. The mandatory 72-hour monitoring should have been implemented immediately.
Reporting requirements exist to create external oversight and accountability for nursing facilities. When facilities fail to report incidents to appropriate authorities, they deny residents the protection these systems are designed to provide. The Ombudsman serves as an independent advocate for nursing home residents, investigating complaints and working to resolve issues. The Department of Public Health monitors facility compliance with safety standards and can intervene when patterns of concern emerge. Law enforcement involvement may be necessary when injuries suggest possible criminal activity.
The Social Work Assistant confirmed during a concurrent interview and record review that reporting to the Department of Public Health ensures the facility has taken necessary steps and protects patient safety. This external validation provides an important check on facility practices and helps identify systemic issues that internal processes may miss.
Violation of Facility's Own Policies
The facility's written policies demonstrated awareness of proper procedures, making the failures particularly troubling. The facility's Unusual Occurrence Reporting policy, revised in September 2023, specifically required reporting of events affecting the health, safety, or welfare of residents, including allegations of abuse, neglect, and misappropriation of resident property.
The facility's Abuse Prevention Program policy, revised June 18, 2024, outlined comprehensive requirements including protecting residents from abuse by anyone, requiring staff training on abuse prevention and identification, assessing all possible incidents of abuse, and investigating and reporting allegations within federally required timeframes. Despite these clear written standards, the facility failed to implement them when actual incidents occurred.
The disconnect between written policies and actual practice raises questions about staff training, administrative oversight, and quality assurance systems. Policies serve little purpose if they remain theoretical documents rather than guiding actual facility operations. Effective implementation requires ongoing staff education, regular monitoring of compliance, and prompt correction when deviations are identified.
Medical and Safety Implications
The failures documented in this inspection created multiple risks for residents. When facilities do not properly investigate incidents between residents, they cannot determine whether room assignments need to be changed, whether care plans require modification, or whether behavioral interventions are necessary. The dispute between Residents 3 and 4 involved allegations of financial exploitation combined with physical violence and racial slurs, suggesting a complex situation requiring careful assessment and appropriate interventions.
For Resident 5, the failure to investigate the facial bruising meant potential ongoing risk of harm. Without determining how the injury occurred, the facility could not implement measures to prevent recurrence. If the injury resulted from a fall or contact with equipment, environmental modifications might be needed. If another person caused the injury, different protective measures would be required.
The absence of required monitoring meant the facility could not properly assess the emotional and psychological impact of these incidents on the residents involved. Physical injuries represent only one dimension of harm from such incidents. Residents may experience fear, anxiety, or other emotional responses that affect their quality of life and overall well-being.
Additional Issues Identified
The inspection also noted concerns about administrative oversight and accountability. The Administrator's job description specified responsibility for directing and coordinating all facility activities to ensure the highest quality of care, with hours to be determined by programmatic needs. The systematic failures in investigating and reporting serious incidents suggested inadequate administrative oversight of these critical safety functions.
The inspection revealed gaps in the facility's quality assurance processes. Multiple serious incidents occurred over a short timeframe without triggering the facility's internal monitoring systems. This pattern suggested the need for enhanced systems to identify and respond to safety concerns promptly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Temple Park Convalescent Hosp from 2024-08-09 including all violations, facility responses, and corrective action plans.
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