Other·February 2, 2024

Health & Safety Code (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) A failure to comply with the requirements of this section shall be a class "B" violation. On 12/11/23 at 8 a.m. an unannounced visit was conducted at the facility to perform the facility's recertification survey. During an interview on 12/11/23 at 11:45 a.m. with Patient 1, Patient 1 alleged Licensed Nurse 1 (LN 1), "raised his hand at me" and added LN 1 made a balled-up fist and raised it over his head as if LN 1 would hit Patient 1. Patient 1 expressed LN 1 had been intimidating during this incident. The facility failed to report this allegation of abuse to the department within 24 hours. During a review of Patient 1's Minimum Data Set (MDS: an assessment tool), dated 11/29/23, the MDS indicated Patient 1 was admitted to the facility in the summer of 2019, with intact memory and cognition and diagnoses that included a history of stroke and weakness on one side of the body. During an interview on 12/13/23 at 3:21 p.m. with the Social Services Director (SSD), the SSD stated Patient 1 had reported the allegation of aggression by LN 1 on 12/7/23. The SSD acknowledged she had not reported the allegation of abuse, nor did she believe any of the other staff present at the care conference, including the Administrator in Training (AIT), had reported the allegation to the California Department of Public Health (CDPH) either. During an interview on 12/13/23 at 4:57 p.m. with the Administrator (ADM), the ADM confirmed Patient 1 had made an allegation of abuse regarding LN 1 on 12/7/23, which was reported to CDPH on 12/11/23. The ADM acknowledged all allegations of abuse needed to be reported to CDPH and this allegation of abuse had not been reported within the required timeframe. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention," revised January 2013, the P&P indicated, "...each facility staff is considered as a mandatory reporter who shall promptly report any incident of abuse to the appropriate agency which includes but not limited to the Department of Public Health and to the Ombudsman's Office... report the incident immediately and no later than two hours to the Local Law Enforcement Agency, Licensing and Certification Program and Ombudsman's office...abuse is defined as the willful infliction of... intimidation..." In violation of the above cited standards, the facility failed to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours, including but not limited to failure to report an allegation of abuse within prescribed timeframes. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.