Health inspection·October 26, 2023

Health and 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 twenty-four hours. (b) Failure to comply with the requirements of the section shall be a Class B Citation. This citation is written as a result of complaint #CA00852800. An unannounced visit was made to the facility on 7/28/23 and 8/8/23 to investigate an unreported allegation of abuse. The Department determined the facility failed to report and investigate an allegation of abuse after Resident 1 and her family reported to the facility that Certified Nursing Assistant (CNA) 3 was rough to the resident while providing care causing the resident to scream in pain. This failure to report and investigate an allegation of abuse had the potential to expose other vulnerable residents in the facility to abuse. A review of Resident 1's clinical record titled, "Face sheet " (a record of admission), indicated that Resident 1 was admitted in mid-July of 2023 with diagnoses that included fracture of upper and lower end of right fibula (the outer and usually smaller of the two bones between the knee and the ankle). Resident 1's Minimum Data Sheet (MDS - an assessment tool to help measure health status of patients in nursing homes), dated 7/25/23, indicated that, Resident 1 was non-English speaking and needed an interpreter to communicate with a doctor or healthcare staff. Resident 1 was cognitively intact and needed extensive assistance for bed mobility, transfer, dressing, toilet, and personal hygiene. In an interview with Resident 1 and Resident 1's daughter on 7/28/23 at 10:30 a.m., Resident 1's daughter stated that Resident 1's leg looked swollen and discolored. Resident 1 informed her that a CNA grabbed her leg and hurt her. Resident 1 also indicated she feared the CNA. In an interview with Resident 2 on 7/28/23 at 10:45 a.m., Resident 2 stated that she had heard her roommate [Resident 1] scream in pain and pulled the curtain back that separated the residents. She saw CNA 3 at the bedside and stated she told the CNA that was not how you treat [residents]. In an interview on 7/28/23 at 12:30 p.m., with the Director of Nursing (DON), the DON stated that on 7/25/23 around 7:20 p.m., Resident 1's daughter came to her regarding concerns that a CNA [CNA 3] was rough with her mother while providing care. The DON went to assess Resident 1 and asked both Resident 1 and her daughter about the incident. DON stated that she spoke to Resident 2 about the incident as well. The DON stated that she did not report the incident to the necessary authorities. A review of the facility's policy titled "Abuse Prevention and Prohibition Program," revised 10/24/22, indicated, " ...Facility Staff are Mandatory Reporters ...owners, operators, employees, agents, and contractors are obligated by the Elder Justice Act and Dependent Adult Civil protection Act to report or suspected instances of abuse of elder or dependent adults ...Failure to report suspected or known abuse may result in legal action against the individual(s) with holding such information ... " . A review of the facility's policy titled "Elder and Dependent Adult Suspected Abuse & Reporting ", revised 11/28/21, indicated, " ...The Facility should promptly and thoroughly investigate reports of resident abuse ... ". Therefore, the Department determined the facility failed to report and investigate an allegation of abuse after Resident 1 and her family reported to the facility that Certified Nursing Assistant (CNA) 3 was rough to the resident while providing care causing the resident to scream in pain. This violation had a direct or immediate relationship to health, safety, or security of Long-Term Care patients or residents.