Other·April 25, 2023

California Health & 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. (b) Failure to comply with the requirements of this section shall be a Class B Citation. The following reflects the findings of the California Department of Public Health during an unannounced visit to the facility to investigate Entity Reported Incident #:CA00673937 and CA00675988. Representing the Department, HFEN #40019. State Citation B was written. As a result of the investigation, the Department determined the facility failed to report and investigate an allegation of abuse for Resident 1 to the Department immediately or within 24 hours as required by law. A review of the medical record indicated Resident 1 was admitted to the facility in early 2020 with a diagnosis of unspecified dementia (an impaired ability to think, remember, or make decisions which interferes with daily activities). A MDS (Minimum Data Set, an assessment tool), dated 2/1/20, indicated Resident 1 had severe memory problems. A physician's order, dated 1/28/20, indicated Resident 1 was incapable of understanding resident rights. A review of the medical record indicated Resident 2 was admitted to the facility in early 2020 with a diagnosis of bipolar disorder (a mental health condition which causes extreme shifts in mood). A MDS, dated 1/31/20, indicated Resident 2 had no memory problems. A physician's order, dated 1/24/20, indicated Resident 2 was capable of understanding rights and responsibilities. A review of Resident 1's progress note, dated 2/4/20 at 6:24 p.m., indicated Resident 1's Responsible Party (RP) reported Resident 2 had been physically inappropriate by kissing and hugging Resident 1. Resident 1's RP also notified staff Resident 1 had signaled for the RP to get Resident 2 away from Resident 1. A review of Resident 1's progress note, dated 2/4/20 at 11:05 p.m., indicated, " ...one time [Resident 2] went to [RP] and said '[Resident 1] loves me, she really loves me; [Resident 1] wants to [expletive] me.' [RP] verbalized concern of [Resident 2] being ...obsessive towards [Resident 1]. Assures [RP] that writer and charge nurses will try their best to educate [Resident 2] and watch [Resident 1] well and ensure safety." A review of a document titled "Report of Suspected Dependent Adult/ Elder Abuse", dated 2/12/20 and faxed to the Department from the facility, indicated, " Event reported occurred on 2/4/20 involving another resident who was perceived being inappropriate, kissing and hugging and making inappropriate language. Staff intervened by separating both residents." During an interview on 4/25/20 at 4:06 p.m., the Licensed Nurse (LN 1) stated she had heard Resident 2 state he kissed Resident 1. LN 1 confirmed Resident 1's RP reported he witnessed it when he visited and had reported it to staff. LN 1 further stated she did not report the incident because she was under the impression that it was already reported by another nurse. During an interview on 4/29/20 at 10:17 a.m., the Social Services Assistant (SSA) verified Resident 1's RP talked to them about Resident 2 getting close with Resident 1. The SSA confirmed Resident 1's RP requested for Resident 2 to stay away from Resident 1 and not get too close. During an interview on 4/29/20 at 3:24 p.m., the Director of Nursing 1 (DON 1) stated the incident should have been reported to the Department of Public Health immediately. Review of a facility's policy and procedure (P&P) titled "Resident-to-Resident Altercations", revised 12/16, indicated, "All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator... Facility staff will monitor residents for aggressive/ inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator." Review of a facility's P&P titled "Abuse Investigation and Reporting", revised 12/16, indicated, "All reports of resident abuse ...exploitation, mistreatment... shall be promptly reported to local, state, and federal agencies... and thoroughly investigated by the facility. An alleged violation of abuse ... exploitation or mistreatment... will be reported immediately, but not later than... Two (2) hours if the alleged violation involves abuse... Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury..." Therefore, the Department determined the facility failed to follow California Law and facility Policies and Procedures regarding alleged and suspected abuse reporting requirements. It was determined that the facility failed to report and investigate the alleged incident of abuse immediately or within 24 hours when Resident 1's Responsible Party (RP) reported Resident 2 had been physically inappropriate by kissing and hugging Resident 1. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility Patients.