Health inspection·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. The following citation is written because of a facility reported incident (FRI) #CA00779876. An un-announced visit was made to the facility on 4/21/22 to investigate a FRI received on 4/7/22 at 3:17 p.m. regarding an incident of alleged physical abuse sometime in April 2022. It was determined that the facility failed to report the alleged incident of physical abuse that occurred involving Patient 1 and Patient 2 when the facility received the allegation report of abuse sometime in April 2022. Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving physical abuse when Patient 1 allegedly hit Patient 2. 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 1's and Patient 2's event reports (ERs) respectively, dated 4/6/22 at 10:15 a.m., indicated, "...On 4/6/22 past midnight [CNA was stating that it was early morning of 4/6/2022] that patient [Resident 2] was heard screaming from her room, then CNA went to check and found patient on bed, stating that her roommate punch her on the arm then to her right chest..." The Department was notified of the alleged abuse incident on 4/7/22 at 2:42 p.m. A review of the facility's policy and procedure titled, "Abuse Investigation and Reporting," revised July 2017, indicated, "All reports of resident abuse...mistreatment...shall be promptly reported to...state ...agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported...All alleged violations involving abuse...or mistreatment...will be reported...to...The State licensing/certification agency responsible for surveying/licensing the facility...immediately..." Therefore, the facility failed to report immediately, not later than 24 hours all incidents of an alleged violation involving physical abuse when Patient 1 allegedly hit Patient 2. 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.