Other·October 7, 2022

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. Welfare and Institution Code (b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days: (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the suspected abuse results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately, and no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. The following citation was written because of a facility reported incident (FRI) #CA00775062. An un-announced visit was made to the facility on 3/11/22 to investigate a FRI received on 3/1/22 regarding an incident of alleged sexual abuse sometime in February 2022. It was determined that the facility failed to report immediately, the alleged incident of sexual abuse that occurred involving Patient 1 and Patient 2 when the facility received the allegation report of abuse sometime in February 2022. Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving sexual abuse, when Patient 1 entered Patient 2's room and allegedly touched Patient 2's penis. This failure decreased the facility's potential to protect and provide residents with a safe environment. Patient 1 was admitted to the facility in early 2022 with multiple diagnoses, which included Alzheimer's disease (a progressive disease that affects memory, thinking and behavior). A review of a Minimum Data Sheet (MDS, an assessment tool), dated 2/25/22, indicated, Patient 1 had severe memory decline. Patient 2 was admitted to the facility in early 2022 with multiple diagnoses which included fusion of spine lumbar region (surgical procedure to treat spine deformities). A review of a MDS dated 2/25/22 indicated, Patient 2 had intact and no memory decline. A review of Patient 2's Communication and Progress Notes dated 2/27/22, at 8:20 p.m., and 8:52 p.m. respectively, indicated, "Received a phone call from the wife [Patient 2's]...resident [Patient 1] from the other room came inside his room through the bathroom...went to his bedside and touch his [Patient 2] private part... Writer asked resident on what happen and gave the same statement that he told his wife." The facility faxed the initial report on 3/1/22 at 4:32 a.m. The Department received the notification of the abuse incident on 3/1/22 at 8:26 a.m. During an interview on 3/11/22, at 2:18 p.m., the Minimum Data Sheet Nurse (MDSN) stated, the requirement on initial reporting for all suspected abuse was 24 hours. The MDSN acknowledged the alleged incident was not reported within 24 hours. A review of the facility's policy titled, "Abuse Reporting and Investigation," revised December 2016, indicated, "...All reports of resident abuse...shall be promptly reported to...state...agencies (as defined by current regulations) ...All alleged violations involving abuse...Suspected abuse...Alleged abuse...will be reported...within twenty-four hours." Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving sexual abuse when Patient 1 entered Patient 2's room and allegedly touched Patient 2's penis. This failure decreased the facility's potential to protect and provide residents with a safe environment. This violation had a direct or immediate relationship to the health, safety, or security of Patient 2.