LONG BEACH, CA - A Long Beach nursing home violated federal reporting requirements after failing to immediately notify state authorities about a physical altercation between two residents that left one with a broken nose and severe facial injuries.
Delayed Reporting of Serious Incident
The California Department of Public Health inspection of Intercommunity Care Center on August 23, 2024, revealed that facility staff failed to report a resident-to-resident physical altercation within the federally mandated two-hour window. The incident occurred on August 18, 2024, at approximately 8:00 a.m., but was not reported to the California Department of Public Health until 11:55 p.m. that same day - nearly 16 hours later.
The altercation involved two residents on an outdoor patio area, with one resident sustaining significant facial injuries including a deviated nose, nosebleed, and severe facial discoloration. According to the inspection report, the injured resident experienced "purple discoloration to the bridge of her nose, with epistaxis and deviation with pain rated a 10 out of 10."
During the inspection, facility staff observed the injured resident with "yellowish-bluish discoloration on the bridge of her nose, and on both of her cheeks extending under both of her eyes" - injuries that were still visible four days after the incident.
Inadequate Supervision and Training Failures
The incident occurred despite the presence of a certified nursing assistant who was assigned to monitor the patio area. According to the inspection report, the CNA observed two residents sitting "less than an arm's length apart" on a bench when tensions escalated. The staff member witnessed one resident tell the other to "move away," and when compliance didn't occur, the first resident elbowed the second, who retaliated by elbowing the first resident in the nose.
The inspection revealed significant gaps in staff training regarding abuse reporting procedures. The supervising registered nurse on duty stated he "was not familiar with how to fax or call the CDPH and he had not received an in-service or training on the facility's abuse reporting process." Similarly, the monitoring CNA reported not remembering "receiving an in-service or training within the last few months pertaining to abuse or abuse reporting."
Federal regulations require nursing homes to maintain adequate supervision to prevent incidents between residents, particularly those with cognitive impairments. The injured resident had severely impaired cognition and was diagnosed with dementia, bipolar disorder, and schizophrenia, conditions that can affect judgment and increase vulnerability to conflicts with other residents.
Medical Impact and Consequences
The physical injuries sustained in this incident represent serious medical complications that required immediate assessment and ongoing monitoring. A deviated nose, particularly one accompanied by severe pain and bleeding, can indicate a nasal fracture that may require surgical intervention if left untreated. The extensive facial bruising documented in the inspection - extending from the nose bridge to both cheeks and under both eyes - suggests significant trauma that likely caused considerable discomfort and potential complications.
For residents with cognitive impairments, physical trauma can exacerbate existing conditions and lead to increased confusion, agitation, and behavioral changes. The injured resident's underlying mental health conditions, including bipolar disorder and schizophrenia, could have been further destabilized by the traumatic experience, potentially requiring adjustments to psychiatric medications and increased monitoring.
Prompt medical evaluation following such incidents is critical to assess for potential complications such as concussion, internal injuries, or other trauma that may not be immediately visible. The delay in proper reporting could have compromised the resident's access to specialized medical care and appropriate follow-up treatment.
Systemic Failures in Quality Assurance
The inspection uncovered broader institutional failures beyond the immediate reporting violation. The facility's Quality Assurance and Performance Improvement Committee had scheduled abuse prevention as a discussion topic for their July 9, 2024 meeting but failed to address it during the actual meeting. The Administrator acknowledged that "they did not have the time to fit it into the QAPI meeting," representing a failure in systematic oversight.
Additionally, the facility had previously been cited for abuse-related deficiencies during a May 28, 2024 survey and had developed a plan of correction that included ensuring all staff received mandatory abuse reporting training. However, the inspection revealed that this corrective action plan was not effectively implemented, as evidenced by staff members' lack of knowledge about reporting procedures.
The Director of Nursing, who had only begun working at the facility in July 2024, stated she was unaware of the facility's plan of correction or Quality Assurance discussions related to abuse prevention. This lack of continuity in leadership and communication created gaps in institutional memory and accountability.
Regulatory Requirements and Industry Standards
Federal regulations mandate that nursing homes report suspected abuse, neglect, exploitation, or injuries of unknown origin to the state agency immediately, but no later than two hours after the incident occurs or after becoming aware of the incident. This requirement exists to ensure rapid investigation and protection of vulnerable residents.
The two-hour reporting window serves multiple critical purposes: it allows state investigators to interview witnesses while memories are fresh, preserves physical evidence, enables immediate implementation of protective measures, and ensures that patterns of incidents are quickly identified and addressed.
Nursing homes are also required to maintain comprehensive abuse prevention programs that include regular staff training, clear reporting protocols, adequate supervision of residents, and effective quality assurance oversight. The facility's own policy manual emphasized the importance of these systems in protecting residents and maintaining regulatory compliance.
Additional Issues Identified
The inspection also documented concerns about the adequacy of patio supervision, noting that the monitoring area was large with "areas that were hidden from view" and that typically two staff members were assigned to monitor the space, though only one was present during the incident.
The facility's communication and leadership structure showed weaknesses, with the Administrator citing "personal circumstances" as the reason for his unavailability during the critical reporting period, and the Director of Nursing focusing on resident care needs rather than fulfilling mandatory reporting obligations.
The inspection findings highlight the interconnected nature of quality care systems in nursing homes, where failures in training, supervision, communication, and administrative oversight can combine to create environments where serious incidents occur and are not properly addressed, potentially placing residents at continued risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Intercommunity Care Center from 2024-08-23 including all violations, facility responses, and corrective action plans.
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