Health inspection·September 27, 2024

REGULATION VIOLATION(S) F609 - REPORTING ALLEGATIONS OF ABUSE (Rev. 173, Issued: 11-22-17; Effective: 11-28-17; & Implementation: 11-28-17) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to ensure an allegation of physical abuse made by a resident (Resident 1) was reported to the California Department of Public Health (the Department) no later than two hours after the allegation was made. The facility further failed to submit the results of its investigation of the abuse allegation to the Department within five working days of the incident. These failures prevented the Department from timely investigating Resident 1's abuse allegation and placed all facility residents at risk of abuse. A review of online communication from the Ombudsman (an advocate for the elderly) to the Department dated 12/10/21, at 12:39 p.m., indicated that Resident 1 had reported to the Ombudsman an allegation of abuse concerning Certified Nursing Assistant A (CNA A) on 12/10/21. The Ombudsman communication indicated Resident 1 reported CNA A had thrown a bottle of lotion at her on 11/25/21. During an interview on 12/10/21, at 2:28 p.m., Resident 1 stated on 11/25/21, at 2:30 p.m., during a bed bath in her room, CNA A threw a three-inch long plastic lotion container on her shin from approximately three feet. Resident 1 stated she felt "severe pain" when the lotion bottle hit her leg. Resident 1 stated she confronted CNA A who then left the room. Resident 1 stated a few minutes later the Director of Nursing (DON) entered her room and stated that CNA A had reported to her that she (Resident 1) had accused him (CNA A) of intentionally hurling a bottle of lotion at her. Resident 1 reiterated to the DON that CNA A had thrown a lotion container at her. During an interview on 12/10/21, at 3:15 p.m., the DON stated that on 11/25/21, in the afternoon, CNA A came to her office and reported that Resident 1 had accused him of throwing a bottle of lotion at her. The DON stated CNA A denied the allegation. After interviewing CNA A, the DON stated she went to see Resident 1 in her room. The DON stated Resident 1 did not appear to be in distress or in pain. The DON stated Resident 1 told her that CNA A had thrown a small lotion container on her shin during a bed bath. The DON stated she assessed Resident 1's legs and found no visible injuries. The DON stated she believed no physical abuse had occurred, and for this reason did not report the incident to the Administrator or the Department. During an interview on 12/10/21, at 3:45 p.m., the Administrator stated he had not been informed by the DON or anybody else of Resident 1's abuse allegation against CNA A dated 11/25/21. The Administrator stated because he was unaware of the abuse allegation, he had not reported it to the Department and had not conducted an investigation of the allegation or kept any records of it. A review of facility policy titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", Revised April 2021, indicated: "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law." "The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies... a) The state licensing/certification agency responsible to surveying/ licensing the facility; b) The local/state ombudsman..." "The Administrator... provide the appropriate agencies... with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." The violation of the regulation had a direct relationship to the health, safety, or security of patients.