Health inspection·September 8, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Entity Reported Incident ERI #: CA00782248 Representing the Department. HFEN #45875 F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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 follow the aforementioned regulation to keep patients from abuse when CNA 1 continued to work as a direct care giver before a thorough investigation of physical abuse allegations for Patients 1 and 2. Patient 1 was a 101-year-old female, admitted to the facility on 4/9/2022. She had diagnoses including displaced fracture of base of neck of right femur (break of thigh bone), weakness, Type 2 Diabetes Mellitus (high blood sugar), glaucoma (eye condition that may cause vision loss) and falls. During a record review of Patient 1's Minimum Data Set (MDS- An assessment tool used to guide care) dated 4/13/22, the MDS indicated, Brief Interview for Mental Status (BIMS- cognition assessment) score was 13 out of 15, indicating intact cognitive function. During an observation and interview on 5/20/22, at 8:10 a.m. with Patient 1, Patient 1 stated, on 4/24/22 at lunch time she was in bed and holding lunch menu in her right hand. CNA 1 grabbed menu from her, "squeezed her wrist hard" and bandage came off her right wrist. Patient 1 stated, she had a broken skin on her right wrist, which started to bleed after the bandage came off. Patient 1 stated skin tear "hurt quite a bit" after and it made her feel "upset" and "angry." During an interview with LVN 1 on 5/20/22, at 9:05 a.m., LVN 1 stated, around 1:00 p.m., on 4/24/22, a family representative (FR 1) informed her of Certified Nursing Assistant (CNA 1) grabbed Resident 1's "wrist" and caused a "skin tear to open". LVN 1 stated, Patient 1's skin tear was "a quarter sized skin flap" and it was "bleeding". LVN 1 stated, she cleansed the skin tear with saline and applied anti-biotic ointment and bandage. LVN 1 stated, CNA 1 continued to stay in facility until end of shift around 2:00 p.m. even after an abuse allegation was made against her. LVN 1 stated, she completed "a grievance form" regarding the abuse allegation by Resident 1. During a record review "Resident Grievance/Complaint Form" dated 4/24/22, LVN 1 documented CNA 1 "grabbed Patient 1's arm" at 12:49 p.m. in Patient 1's room. Under actions or recommendations LVN 1 documented "CNA 1 should no longer work with Patient 1". Patient 2 was a 64-year-old female, admitted to the facility on 3/8/2021. She had diagnoses including Fracture of Left Femur (break of thigh bone), Chronic Pain Syndrome, Hypertensive Heart Disease with Heart Failure and History of falling. During a review of Patient 2's MDS, dated 2/22/22, the MDS Section C indicated, Resident 2's BIMS score was 12 out of 15, which indicated intact mental status. During a review of Patient 2's "Progress Notes" completed by LVN 1 dated 4/25/22, the progress notes indicated, "writer asked Patient 2 to explain what happened. Patient 2 stated, when she asked CNA 1 to look for charger, CNA 1 responded she had no time, then Patient 2 stated, she tried to a call out to her Alexa (voice activated device) to call 911, CNA 1 spanked left leg before leaving". During an interview with the Patient2 on 5/20/22, at 8:12 a.m., Patient 2 stated, on 4/24/22, CNA 1 hit her leg when she asked CNA 1 to look for her phone charger. Patient 2 further stated, "she should help me not hurt me" and that made her "feel mad". During a phone interview with CNA 1 on 5/23/22, at 11:30 a.m. CNA 1 stated, around 11:30 a.m., on 4/24/22, she served lunch meal trays to the patients. CNA 1 stated, she helped Patient 1 out of the bathroom and gave the meal tray. CNA 1 stated, she then left the room and was told by LVN 1 that she could not enter Patient 1's room or assist her. CNA 1 stated, LVN 1 told her she could continue to serve meal and provide care for her other assigned patients (Patient 2, 4, 5, 6, 7, 8 and 9. CNA 1 stated, she assisted Patient 2, 4, 5, 6, 7, 8 and 9 with repositioning and personal hygiene until 2:30 p.m. on 4/24/22. CNA 1 stated, she came back to work for her regular patient care assignment at 6:30 a.m. on 4/25/22. CNA 1 stated, she continued to provide care for Patient 2, 4, 5, 6, 7, 8 and 9 until she was sent home at 10:00 a.m. on 4/25/22. During a phone interview with the DON on 5/20/22 at 9:55 a.m., the DON stated, she was the one who completed the Investigation Summary for abuse allegations made by Patient 1 and Patient 2 on 4/29/22. The DON stated, she spoke to some residents to complete a thorough abuse investigation, however was "unable to recall" the number and name of patients participated in abuse investigation and the date and time she conducted the interviews. The DON stated, she would only document the interviews with other patients if they complained about CNA 1. The DON stated, CNA 1 was not removed from resident care area until around 11:00 a.m. on 4/25/22. During a review of Certified Nursing Assistant 1's employee timecard, "State Audit Report", for the period of 4/21/22 -5/21/22, the audit report indicated, CNA 1 left the facility on 4/24/22 at 2:38 p.m. and on 4/25/22 at 2:52 p.m. During an interview with Administrator (ADM) on 5/20/22, at 12:10 p.m., the ADM stated, facility should have removed CNA1 from resident care area "immediately" after Patient 1 reported a physical abuse allegation against CNA 1. The ADM also stated, facility did not follow its protocol to complete a thorough abuse investigation. During a concurrent interview and record review on 5/20/22, at 11:48 p.m., with DSD, facility's Policy and Procedure (P&P) titled, "Abuse prohibition and prevention policy and procedure and reporting reasonable suspicion of a crime in the facility policy and procedure," revised on 3/2018 was reviewed. The P&P section F Investigation indicated, "1. All incidents of suspected or alleged abuse will be promptly investigated by the assigned staff, who will be informed of the nature of the incident and continue the investigation process. The investigation and report shall include: ... j. Interviews facility staff members who have had contact with the resident during the period of the alleged incident; ... k. Interviews the resident's roommate, family members, and visitors; ...l. Interviews other residents to whom the accused employee provides care of services; ...o. Prepares an investigation report documenting findings of the investigation." Therefore the facility failed to follow the aforementioned regulation to keep patients from abuse when CNA 1 continued to work as a direct care giver before a thorough investigation of physical abuse allegations for Patients 1 and 2.