LOS ANGELES, CA - State inspectors documented significant reporting failures at Infinity Care of East Los Angeles after facility staff did not file required notifications about an alleged verbal abuse incident between residents within the mandatory two-hour timeframe, potentially leaving vulnerable individuals at risk.
Critical Breakdown in Reporting Protocol
During a June 2024 inspection, surveyors identified that facility staff failed to follow established protocols when an incident of alleged verbal abuse occurred between two residents in May. The situation involved Resident 77, who reportedly yelled at Resident 28 using socially inappropriate language while a nursing assistant was helping Resident 28 to the shower on the morning of May 8, 2024.
The incident came to light through documentation in Resident 77's Interdisciplinary Team meeting notes dated May 6, 2024, which referenced that Certified Nursing Assistant 2 was present when Resident 77 directed inappropriate verbal language toward Resident 28. However, the facility did not report this incident to the required authorities within the mandated two-hour window, as outlined in both federal regulations and the facility's own policies.
Resident 28, who has intact cognitive abilities and can make her own decisions, described her reaction to the incident during interviews with inspectors. She confirmed that the next day, she spoke with the Social Services Director and MDS Nurse about what had occurred, expressing that "no one is allowed to or has the right to speak to her like that." The resident stated the encounter made her feel "very angry."
Both residents involved had documented cognitive capacity to understand and make decisions according to their medical records. Resident 28, admitted with diagnoses including bilateral osteoarthritis of the knee and right-sided weakness following a stroke, required significant assistance with daily activities but maintained clear mental function. Resident 77, admitted with atherosclerotic heart disease and cerebral infarction, similarly possessed intact cognitive skills for daily decision-making.
Understanding the Medical and Psychological Impact
Verbal abuse in nursing home settings presents serious concerns beyond the immediate discomfort of an unpleasant encounter. The psychological effects of such incidents can be particularly damaging for individuals already dealing with medical conditions and the vulnerabilities that come with requiring long-term care.
Research consistently demonstrates that verbal aggression can trigger stress responses that affect both mental and physical health. For residents with cardiovascular conditions like Resident 77's atherosclerotic heart disease, or those recovering from strokes like both residents in this case, emotional distress can potentially exacerbate existing conditions. Elevated stress hormones can increase blood pressure, affect heart rate, and potentially interfere with rehabilitation progress.
The impact extends beyond physiological responses. Residents who experience verbal abuse may develop anxiety about common daily activities, potentially leading to social withdrawal or reluctance to accept necessary care. When an incident occurs during routine personal care like showering—an already vulnerable moment for many residents—the psychological impact can be compounded. This may result in residents avoiding or resisting necessary hygiene assistance, which can then lead to secondary health complications.
Furthermore, when facilities fail to properly address and investigate such incidents, it can create an environment where residents feel unsafe or unheard. This undermines the fundamental trust necessary for therapeutic relationships between residents and caregivers, and can negatively affect overall quality of life and health outcomes.
Regulatory Requirements and Facility Policy Violations
Federal regulations establish specific timeframes for reporting allegations of abuse in nursing facilities. These requirements exist to ensure rapid response, proper investigation, and immediate protection for all residents involved. The two-hour reporting window serves multiple critical functions: it allows for timely investigation while details are fresh, enables immediate intervention if needed, and ensures appropriate oversight agencies can take action to prevent recurrence.
According to the facility's own "Abuse Investigation and Reporting" policy, revised in March 2024, all alleged violations involving abuse must be reported within two hours to multiple entities. This includes the state licensing and certification agency responsible for surveying the facility, the state ombudsman who advocates for nursing home residents, law enforcement officials, and adult protective services where state law provides jurisdiction in long-term care facilities.
The facility's policy specifically categorized verbal abuse as including "the use of verbal, written or gestured communication, or sounds, to residents within hearing distance" and provided examples such as "harassing a resident," "mocking, insulting, ridiculing," and "yelling or hovering over a resident, with the intent to intimidate."
During the inspection, multiple staff members demonstrated understanding of these requirements. The Social Services Director confirmed that "verbal abuse is when someone says something to someone that is offensive and unacceptable" and acknowledged that "the timeline for reporting is within two hours" and that the witnessing nursing assistant "should have reported the incident to the supervisor and charge nurse." The Director also emphasized that reporting allegations to the state survey agency was important "so it will not happen again for the safety and wellbeing of the residents and staff involved."
The Director of Nursing similarly stated that verbal abuse involves situations where "a person directly screams at another person by swearing and using foul language" and confirmed that "if a resident was offended by this type of behavior, then it was not acceptable and should be considered an allegation of abuse." The DON acknowledged the allegation "should have been reported by CNA 2 within two hours or earlier to the authorities and the facility's abuse coordinator."
Consequences of Inadequate Reporting Systems
When nursing facilities fail to properly report alleged abuse, the consequences extend beyond the individuals directly involved in the incident. The Director of Nursing explained during the inspection that failure to investigate allegations of abuse "could psychologically harm the resident, could be detrimental to the resident's mental health and the incident could possibly happen again."
This statement captures the core concern with reporting failures: without proper investigation and intervention, patterns of problematic behavior may continue unchecked. When incidents go unreported, facilities miss opportunities to implement corrective measures, provide additional training to staff, or make environmental modifications that could prevent similar situations.
The failure also means that external oversight agencies cannot fulfill their protective functions. State survey agencies, ombudsmen, and law enforcement each play distinct roles in investigating allegations and ensuring resident safety. When they are not notified promptly, the ability to gather evidence, interview witnesses while memories are fresh, and take immediate protective action is compromised.
For Certified Nursing Assistant 2, who witnessed the incident but did not initiate the required reports, the breakdown represented both a failure in individual response and potentially a gap in facility training or culture around abuse reporting. The nursing assistant's presence during the incident placed her in a critical position to activate the facility's protective systems, yet the necessary reports were not filed within the mandatory timeframe.
Standards for Abuse Prevention Programs
Industry best practices call for comprehensive abuse prevention programs that go beyond written policies to create cultures of vigilance and immediate response. These programs typically include regular staff training on recognizing various forms of abuse, understanding reporting requirements, and knowing how to activate reporting systems quickly.
Effective programs emphasize that all staff members—regardless of their position—have both the authority and responsibility to report concerns immediately. This includes creating clear reporting pathways that do not require multiple layers of approval before external notifications are made, particularly for incidents that clearly meet abuse criteria.
Training should address the various types of abuse, including resident-to-resident interactions that may constitute verbal abuse. Staff need clear guidance on distinguishing between typical social conflicts and situations that rise to the level requiring immediate reporting. Given that both residents in this case had intact cognitive abilities, the situation highlights the importance of recognizing that verbal abuse can occur between cognitively intact individuals and still requires the same urgent response protocols.
Additionally, strong abuse prevention programs include regular auditing of incident reports and follow-up procedures to ensure compliance with reporting timelines. Facilities should track the time between when incidents occur or are witnessed and when required external notifications are completed. Any patterns of delayed reporting should trigger immediate retraining and system evaluation.
Additional Issues Identified
The inspection narrative also documented that the incident was eventually addressed through the interdisciplinary team process, with documentation appearing in meeting notes. However, this internal documentation process did not substitute for the required external reporting to regulatory agencies, the ombudsman, and law enforcement.
The facility's "Abuse Reporting" policy, revised in April 2023, outlined a clear step-by-step process requiring staff to "Call California Department of Public Health (CDPH), Long term Care (LTC) Ombudsman, and Police Department (PD) within two hours of the alleged event." The policy required responding "appropriately to all alleged violations."
Staff interviews revealed widespread understanding of these requirements among leadership positions. A Certified Nursing Assistant stated during the inspection that "verbal abuse is when bad words are used, yelling, saying something degrading or negative" and confirmed that the incident between the two residents "was considered verbal abuse" and "should have been reported within two hours to CDPH, the ombudsman, and the police."
The deficiency citation noted that this practice "has the potential to result in unreported abuse in the facility and failure to protect Resident 28 and other residents from abuse," indicating inspectors' concerns about systemic vulnerabilities rather than an isolated incident.
The findings raised questions about whether the facility's actual practices aligned with its written policies and whether staff faced barriers—practical or cultural—to activating reporting systems promptly. The gap between staff knowledge of requirements and actual reporting practices suggested potential issues with accountability systems, supervision, or the facility's response culture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Infinity Care of East Los Angeles from 2024-06-07 including all violations, facility responses, and corrective action plans.
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