Other·March 8, 2023

F0609 Reporting of Alleged Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Health and Safety Code 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. Health and Safety Code 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced visit to the facility on 1/18/23 at 9:45 a.m. for the investigation of a complaint received by the Department. As a result of the investigation, the Department determined that the facility failed to report an allegation of physical abuse within 24 hours as required, when a Certified Nursing Assistant (CNA) allegedly abused a resident (Resident 1) on 8/17/22. This failure decreased the facility's ability to protect vulnerable residents and provide a safe environment. Resident 1 was admitted to the facility on 6/27/22 with diagnoses including encephalopathy (disease of the brain that alters brain function or structure) and diabetes mellitus (disease that affects how the body regulates blood sugar). A review of a communication email sent from Resident 1's daughter to the Administrator (ADM) on 8/17/22, at 8:02 a.m., indicated Resident 1's daughter had attached an alleged abuse incident that had occurred at the facility by a staff member. A review of a communication email sent from the ADM to Resident 1's daughter on 8/17/22, at 12:13 p.m., indicated ADM had talked to Resident 1 and her family, "...and did not believe it was [an] abuse..." A review of a communication email sent from Resident 1's daughter to the ADM on 8/18/22, at 7:08 a.m., indicated Resident 1's daughter talked to her mom and sister "...and they made it very clear to... [the ADM] that it was a slap on the hand numerous times..." Resident 1's daughter further stated wanted to make it clear that it was a CNA who slapped her mother's wrist. A review of a communication email sent from the ADM to Resident 1's daughter on 8/18/22, at 8:56 a.m., indicated Resident 1 was not able to identify the CNA who allegedly abused her. The ADM stated she immediately removed the CNA from the assignment and assured Resident 1's daughter that if that was the CNA accused of abuse, they would no longer be caring for her mother. A review of Resident 1's progress notes, dated 8/18/22, included a summary of the discussion that occurred between Resident 1, her spouse, daughter, the Social Services Director (SSD), and the ADM. It also indicated, "on 8/15/22... [Resident 1] reported to her family that a staff member (CNA) had touched her hand during a Hoyer[(r)] lift transfer..." During an interview on 1/18/23, at 12:26 p.m., with the SSD, SSD stated he and the ADM went to investigate and find out what happened. The SSD stated, "We did not believe that was abuse...I talked to [ADM] who was the abuse coordinator in there and she said no this is not abuse and we're not going to report...this is just the CNA touched [Resident 1's] hand to get her to stop touching down in her private area...we've both said no we don't think this rises to the level that we need to report this as abuse..." SSD further stated if Resident 1's daughter notified the facility via email about an alleged abuse incident then SSD would immediately notify the abuse coordinator, "...and after that it would be reporting to the [California] Department of Public Health [CDPH] immediately within two hours...we should report before starting our investigation." During an interview on 1/18/23, at 12:58 p.m., with the ADM, ADM acknowledged her attendance to a meeting with the SSD, Resident 1, Resident 1's daughter, and Resident 1's spouse on 8/18/22 due to a concern raised by Resident 1's family. ADM stated, "...The family kept saying that there was an abuse and that [Resident 1] was slapped... [Resident 1's] family insisted that she was slapped. We didn't know the CNA. [Resident 1] couldn't remember." ADM also acknowledged that she received an email from Resident 1's daughter on 8/17/22 notifying her about the alleged abuse incident and further stated that the next step that was supposed to be done after receiving the email was to complete the SOC 341 form [Report of Suspected Dependent Adult/Elder Abuse] and report to CDPH within two hours of receiving an abuse allegation. A review of the facility's policy and procedure titled, "Elder and Dependent Adult Suspected Abuse & Reporting," dated 11/28/21, indicated, "In response to allegations of abuse...the facility...is responsible for completing a telephone report and written SOC 341 report to either the local Long Term Care Ombudsman, local law enforcement and the licensing agency (CDPH) immediately or not later than 24 hours. The written SOC 341 report must be completed within 24 hours unless the allegation involves abuse or result in serious bodily injury." In violation of the above cited standards, the facility failed to report to the Department the allegation of physical abuse by a CNA to Resident 1 within 24 hours after its occurrence on 8/17/22. This violation had a direct or immediate relationship to the health, safety, or security of residents.