Health inspection·March 17, 2022

F609 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. The following citation is written as a result of a facility reported incident #CA00760924. An unannounced visit was made to the facility to investigate a facility reported incident, received on 11/12/21, at 4:20 p.m., related to an altercation between two residents. The Department determined the facility failed to report an allegation of abuse immediately, or within 24 hours as required, when Licensed Nurse (LN) 2, the Administrator, and the Director of Nursing did not report alleged abuse of Resident 2 by Resident 3 on 11/10/21, per the facility's policy, and State law. This failure put Resident 2, and other residents in the facility, at risk for abuse. Findings: Resident 2 was admitted to the facility in late 2021 with diagnoses which included a right hip fracture, dementia (symptoms affecting memory, thinking and social abilities severe enough to interfere with daily life), depression, and muscle weakness. Resident 3 was admitted to the facility in late 2020 with diagnoses which included dementia, anxiety, a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with hallucinations (when someone sees, hears, smells, tastes or feels things which don't exist outside of their mind), and depression. A review of Resident 3's plan of care, dated 3/4/21, indicated Resident 3 had socially inappropriate and disruptive behaviors. These behaviors included cursing, threatening, and hitting staff. Interventions for these behaviors included assessing whether the behavior endangered other residents, and if so, intervene when necessary. The plan of care read to avoid over-stimulation and included examples which were listed as noise, crowding, and other physically aggressive residents. A review of a nurse progress note, dated 11/10/21, indicated approximately one hour after breakfast Resident 3 became "Irate and verbally explicit". The note read Resident 3, "...stormed out of her room carrying a bin of her belongings and attempted to elope the facility". The front door alarm sounded and staff members who were outside convinced Resident 3 to go back inside, and staff heard yelling from Resident 3's room a few minutes later. The nurse documented Resident 2 and Resident 3 now shared a bathroom located between their two rooms and were both yelling at each other to get out of the bathroom. The nurse intervened and escorted Resident 2 out of the bathroom. The nurse realized the bathroom door handle was broken on Resident 2's side of the room and called maintenance to fix it. Both residents were left alone and "several minutes later banging was heard". When maintenance arrived with parts to fix the door handle Resident 2 was witnessed seated on the floor. The note indicated Resident 3 was standing over Resident 2 and when asked, Resident 2 stated Resident 3 had pushed her. Resident 2 complained of right elbow and knee pain and was noted to have a lump on the forehead. Resident 2's physician was notified of the incident and ordered Resident 2 be sent to the hospital for further evaluation. A review of a nurse progress note, dated 11/10/21, indicated the nurse called the hospital late in the evening and was told Resident 2 was being admitted for a right hip fracture. During an interview on 11/29/21, at 10:11 a.m., the Director of Nursing (DON) stated Resident 3 was "restless and irritated" on 11/10/21 and attempted to leave the facility. A short while later the DON was informed of the incident between Resident 2 and Resident 3 and upon arrival to the room, Resident 2 was on the floor and stated Resident 3 had hit Resident 2. During an interview on 11/29/21, at 3:50 p.m., the DON was unaware why Resident 2 was moved to that particular room and stated ideally the two should not be next to each other. The DON went on to say it may have been missed there was a shared bathroom between the two rooms. During an interview on 1/23/22, at 2:29 p.m., the DON stated incidents of abuse should be reported within two hours if there was an injury, and within 24 hours without injury. A subsequent interview with the DON on 1/27/22, at 4:09 p.m., revealed the incident between Resident 2 and Resident 3 was not reported until after 8 p.m. on 11/10/21. A review of the facility's policy and procedure titled, "Abuse and Neglect Prevention Management", revised 12/21/04, indicated, "...It is the policy of the facility to ensure our residents safe and free from abuse...our residents have the right to be free from abuse...by anyone, including...other residents...the reporting of alleged abuse...will be completed according to state and federal guidelines..." Therefore, the Department determined the facility failed to report an allegation of abuse immediately, or within 24 hours as required, when Licensed Nurse (LN), the Administrator, and the Director of Nursing did not report alleged abuse of Resident 2 by Resident 3 on 11/10/21, per the facilities policy, and State law. This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility residents.