Health inspection·February 12, 2025

REGULATION VIOLATION(S) Health & Safety Code § 1418.91(a)(b) (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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 1/7/25 at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of patient rights. The department determined the facility failed to report an allegation of verbal abuse between Patient 1 and Physician A to the California Department of Public Health (CDPH, to be referred to the Department from here on). This failure prevented the Department from investigating the allegation of abuse and continued to place Patient 1 and other patients at risk for abuse by Physician A. A review of Patient 1's medical record indicated admission to the facility on 3/20/23, with a medical history that included diagnoses of insomnia (a sleep disorder characterized by persistent difficulty falling or staying asleep) and borderline personality disorder (a complex mental health condition characterized by intense and unstable emotions, impulsive behaviors, and difficulty in maintaining relationships). A review of Patient 1's Minimum Data Set (MDS, a patient assessment tool used to identify patient care needs) dated 12/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of cognitive status) score of 14 of 15 which indicated no cognitive impairment. Patient 1 was his own responsible party. A review of Patient 1's progress note written by Licensed Staff B on 10/25/24 at 10 a.m., indicated, "... [Physician A] greeted the [Patient 1 by a nickname] then the [Patient 1] didn't want the way he calls his name and telling he should be called by his name and so the [Physician A] called him by his surname. The [Patient 1] felt upset...as he felt he was abused that way and...the [Physician A] responded, 'Go ahead and report me.' After that the [Patient 1]...provoking the [Physician A]...and the [Physician A] responded, 'Aren't you a shit?'...[Patient 1] relayed immediately to the Administrator and Charge nurse and requested to be seen by another wound doctor...[Patient A] talked to me and asked me why I did not tell to the Administrator the incident, I explained to him that I told it just happen that he reported first before me as I'm still attending the Weekly wound [physician] rounds." A review of Patient 1's behavior note dated 10/25/24 at 2:48 p.m. indicated, "[Patient 1] is 'upset' with the [Physician A] that had visited him today. [Patient 1] reported that the [Physician A] had said 'aren't you being a shit?'. [Patient 1] found the statement offensive and states that the [Physician A] is not allowed to see him anymore." During an interview on 1/7/25 at 3:15 p.m., Licensed Staff B stated she and Physician A entered Patient 1's room to assess and treat the wound on his right foot. Physician A greeted Patient 1 by a nickname. Patient 1 notified Physician A he preferred to be referred to by his legal first name. Physician A then addressed Patient 1 by his surname. Patient 1 became upset because Physician A did not refer to him by his legal first name, which led to an argument between them. Physician A then responded to Patient 1, asking, "Aren't you a shit?" Licensed Staff B stated Patient 1 became upset and did not want Physician A to treat him anymore and wanted another doctor. Licensed Staff B confirmed she reported the incident to the Director of Nursing (DON) and Administrator after she completed wound rounds with Physician A on 10/25/24. During an interview on 1/7/25 at 4:29 p.m., the DON confirmed Licensed Staff B reported the incident between Patient 1 and Physician A to her on 10/25/24. The incident was not reported to the Department as verbal abuse. During an interview on 1/9/25 at 1 p.m., the Administrator verified he was the facility's Abuse Coordinator and confirmed the incident between Patient 1 and Physician A was reported to him on 10/25/24. The Administrator also verified the allegation of abuse was not reported to any regulatory agencies. A review of the facility's policy and procedure titled "Abuse-Reporting & Investigations", revised March 2018 indicated, "Notification of Outside Agencies of Allegations of Abuse With No Serious Bodily Injury...The Administrator...will notify within two...hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. The Administrator...will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two...hours." Therefore, the department determined the facility failed to report an allegation of verbal abuse between Patient 1 and Physician A to the Department. This failure prevented the Department from investigating the allegation of abuse and continued to place Patient 1 and other patients at risk for abuse by Physician A. The violation of the regulation had a direct relationship to the health, safety, or security of patients.