Other·June 3, 2021

Health & Safety Code 1489.91(b) (b) A failure to comply with the requirements of this section shall be a class B violation. The facility failed to report alleged physical abuse to California Department of Public Health (CDPH) within 24 hours, for one of three incidents of resident-to-resident altercations, when Resident 1 and Resident 2 had an altercation on 11/22/19; the facility reported the incident to CDPH on 11/25/19. This failure had the potential for the incident to go unreported and to delay interventions to keep other residents safe. On 11/25/19, CDPH received the Facility-Reported Incident for alleged physical abuse between Resident 1 and Resident 2. Review of the Admission Record indicated the facility admitted Resident 1 to the facility on 11/18/19, with a diagnosis of Schizoaffective Disorder Bipolar type (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as delusions, hallucinations, depressed episodes, and manic periods of high energy.) Review of the Admission Record indicated the facility admitted Resident 2 to the facility on 11/08/19, with a diagnosis of Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.) Review of the facility's, "Resident Abuse Report Form," dated 11/25/19, indicated Resident 1 hit Resident 2 in the arm and shouted threatening profanity at Resident 2, which resulted in Resident 1 and Resident 2 engaging in a brief physical altercation, which occurred on 11/22/19 at 5 p.m. Review of Resident 2's Progress Note, dated 11/22/19 at 5 p.m., indicated Resident 2 was in the hallway when Resident 1 hit him in the arm, aggressively, with closed fist and yelled, "You have to die," at Resident 2. With closed fist, Resident 2 hit Resident 1 back; both residents were in a physical fight. Resident 2 was treated for a small scratch to the left side of the neck. During an interview on 1/22/20, at 12:08 p.m., when asked regarding timeframe of reporting alleged abuse, Administrator A stated, "Within two hours if there was serious bodily injury and within twenty-four hours for other types of abuse (no serious injury)." During an interview on 1/22/20, at 12:56 p.m., Licensed Staff B stated the incident between Resident 1 and Resident 2 occurred on 11/22/19 at 5 p.m., and the on-call manager did not have to come to the facility if there was no serious bodily injury. Licensed Staff B stated the CDPH office was closed anyway. Licensed Staff B stated she investigated and reported the incident to CDPH on 11/25/19. The facility policy and procedure, "Step by Step Guide to Abuse & Neglect Intervention, Investigation, and Management," dated 3/20/18, indicated for the facility to report the incident to CDPH within 24 hours. The above violation had a direct or immediate relationship to the health, safety, or security of patients.