Other·April 30, 2025

REGULATION VIOLATION(S) Health & Safety Code 1418 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of physical abuse to the Department of Public Health within two hours when Resident 1 had reported someone had grabbed Resident 1 causing her right ring finger (third finger) and pinky (little finger) to look slightly swollen and bruised. The nurse did not report the physical abuse allegation to the Administrator. This resulted in 1) the investigation not occurring, 2) lack of assessment of Resident 1, and 3) the Department's ability to ensure a complete investigation was initiated timely and ensure interventions were initiated to protect other residents, as well as the resident involved, preventing a reoccurrence of abusive behaviors. A review of Resident 1's "Admission Record, " indicated Resident 1 was admitted to the facility on 6/2/22, with a diagnosis including schizophrenia (a serious mental disorder which affects how a person thinks, feels and acts), major depressive disorder, cognitive communication disorder, vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) with behavioral disturbances, stroke, amongst others. A review of Resident 1's "CPAC (Care Path or Acute Change-NURSING - SBAR (Situation Background Assessment Request) Communication Form and Progress Note," dated 12/16/22, indicated a Certified Nursing Assistant (CNA) reported to License Staff B, Resident 1's right ring finger and pinky had a bruise. Licensed Staff B documented Resident 1's right ring finger and pinky was slight swollen and bruised. Resident 1 said, "Someone grabbed her hand early this morning,? (12/16/22). Resident 1 complained of pain but refused medicine. Licensed Staff B called Resident 1's physician and Resident 1's family and notified both about the "Change of Condition. " During an interview 12/30/22 at 1:50 p.m., the Administrator stated Licensed Staff B was the nurse on duty during the time Resident 1 reported to a CNA someone had grabbed her hand. The CNA reported the allegation to Licensed Staff B. The Administrator stated Licensed Staff B did not report the allegation of physical abuse to him or the DON (Director of Nursing). The Administrator stated all staff was mandated to report harm and/or an allegation of abuse. The Administrator stated Licensed Staff B should have reported the allegation of physical abuse, because she was a mandated reporter (required to report the facts and circumstances that led them to suspect a resident has been abused or neglected). The Administrator stated he knew nothing about Resident 1's 12/16/22 reported allegation of physical abuse when the police came to the facility on 12/28/22 to investigate a reported physical abuse incident by Resident 1. Resident 1, who was transferred to the hospital on 12/27/22, had reported to staff at the hospital, a staff member at the facility had grabbed her by the hand and an X-ray done at the hospital showed a fracture. The Administrator stated Licensed Staff B did not feel the incident reported to her by Resident 1 was a reportable incident of physical abuse. The Administrator stated Licensed Staff B should have reported the allegation to the Administrator and let the Administrator, who was the abuse coordinator decide if it was a reportable incident. The Administrator stated he would have filled out a SOC341 (form filled out by mandated reporters suspecting elder abuse and sent to appropriate authorities). During an interview on 2/1/23 at 4:42 p.m., the DON stated Licensed Staff B did not report to him Resident 1's allegation of someone grabbing her right hand on 12/16/22 causing her right ring finger and pinky to be slight swollen and bruised. The DON stated Licensed Staff B should have reported the incident to the Administrator or to the DON, because the abuse allegation needed to be investigated. The DON stated he knew nothing about the incident. During an interview on 2/1/23 at 4:54 p.m., Social Services stated she was in the facility's business office on 12/27/22, when she saw Resident 1 propelling her wheelchair out of the facility with bags in her left hand and using her right hand to propel her wheelchair. Social Services stated she went out to stop Resident 1, who started cursing and yelling at her. Social Services stated the DSD (Director of Staff Development) helped assist her to try and redirect Resident 1. Social Services stated both her and the DSD tried redirecting Resident 1 to go back into the facility, but Resident 1 started swinging. Social Services stated a CNA was able to talk Resident 1 into going back to her room. Resident 1 had become so aggressive, Resident 1's physician ordered for Resident 1 to be transferred to the ER (Emergency Room) to be assessed. Social Services stated she was not aware of incident addressed on the "SBAR," dated 12/16/22, regarding Resident 1 being grabbed by someone and her right ring finger and pinky being slightly swollen and bruised. Social Services stated if a resident had told her someone had grabbed their hand and bruising was noted, Social Services would have filled out a SOC341 form, reported the allegation to the appropriate authorities such as Ombudsman's [a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] office and CDPH (California Department of Public Health). Social Services stated she would have notified the resident's nurse and the nurse should have notified the Administrator, who was the abuse coordinator. Social Services stated all staff were mandated reporters. Social Services stated if Resident 1's allegation of physical abuse, which was reported to the nurse on 12/16/22, had been reported to the Administrator, an investigation would have been started first by interviewing staff. During an interview on 2/2/23 at 3:42 p.m., Licensed Staff A stated she was taking care of Resident 1 on 12/27/22. Licensed Staff A stated Social Services and the DSD was helping her redirect Resident 1 back into the facility. Licensed Staff A stated Resident 1 did not want anyone to care for her. Licensed Staff A stated she was off on 12/16/22 and never received any report about Resident 1 reporting someone had grabbed her causing her right ring finger and pinky to be sightly swollen and bruised. Licensed Staff A stated she never noticed any bruising and/or swelling of Resident 1's right hand. Licensed Staff A stated Resident 1 never complained of any pain to her right hand. Licensed Staff A stated if Resident 1 or a CNA had reported the allegation of physical abuse to her an investigation would have been started. Licensed Staff A stated she would have reported the allegation to the Administrator, Ombudsman, police and CDPH. During an interview on 2/2/23 at 3:53 p.m., Licensed Staff B stated a CNA did report to her Resident 1's right ring finger and pinky looked bruised. Licensed Staff B stated she assessed Resident 1's right hand and noted Resident 1's right ring finger and pinky was slightly swollen, lightly pink and Resident 1 could move her fingers. Licensed Staff B stated Resident 1 did not report the allegation to the AM shift. Resident 1 did not want anything for pain. Licensed Staff B stated Resident 1 had told her someone had grabbed her right hand sometime in the morning, on 12/16/22. Licensed Staff B stated she reported the incident to Resident 1's physician and called Resident 1's husband, but he did not answer so she called and talked to Resident 1's daughter. Licensed Staff B stated she did not feel the reported incident was physical abuse, so she did not report the incident to the Administrator, nor did she start a SOC341. Licensed Staff B stated she would have completed a SOC341 if she thought what Resident 1 had reported to the CNA and per Licensed Staff B's assessment was an allegation of physical abuse. Licensed Staff B stated Resident 1's right ring finger was slightly pink, often the finger pricked (blood sample obtained) to check Resident 1's blood sugar level. The facility policy/procedure titled, "Abuse Investigation and Reporting,? dated 2/2018, indicated: "Policy: All reports of resident abuse, neglect ... mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Process: Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual ... Reporting: 1. All alleged violations involving abuse, neglect ..., mistreatment, including injuries of an unknown source ... will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: f. The State licensing/certification agency responsible for surveying/licensing the facility, g. The local/State Ombudsman ..., j. Law enforcement ... 2. An alleged violation of abuse, neglect ... or mistreatment (including injuries of unknown source ... will be reported immediately, but no later than: l. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or m. Twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury ... " The facility policy/procedure titled, "Reporting Suspicion of a Crime," dated 6/2018, indicated: "Policy: The Administrator, DON, or any other designated individual will report (within the required time frames) any reasonable suspicion of a crime against a resident to the state Survey Agency and local enforcement agency. Process: ... 2. Once a year, each "covered individual " shall be notified in writing of his or her obligations to report any reasonable suspicion of a crime to the state Survey Agency and at least one local law enforcement agency. a. A "covered individual is defined as anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. 3. Each covered individual must report to the state Survey Agency and at least one local law enforcement agency any reasonable suspicion of a crime against a resident of the facility. ... d. Examples of crimes that would be reportable in any jurisdiction include but are not limited to: ... 4. Assault/battery ... 4. The timing of the reporting will be based on the events that cause suspicion and will be as follows: a. If the event results in serious bodily injury, the suspicion will be reported immediately but not more than two hours after the individual first suspects that a crime has occurred. B. If the event does not result in serious bodily injury, the suspicion will be reported not more than twenty-four hours after the individual first suspects that a crime has occurred. c. "Serious bodily injury " is defined as an injury involving: 1. Serious physical pain ... 5. Medical intervention requirement such as hospitalization, surgery, or physical rehabilitation ... 8. Employees (covered individuals or not) are encouraged to report any reasonable suspicion of a crime ... Therefore, the facility failed to notify the Department within 2 hours of an alleged incident of abuse resulting in an automatic B violation. The violation of the regulation had a direct relationship to the health, safety, or security of residents.