Other·May 3, 2024

Noble Care Center The following reflects the findings of the California Department of Public Health during the investigation of: Facility reported incident # CA00886144 during the Recertification Survey Event ID: BWH311 Representing the Department, HFEN #33424, HFES #44260 State Citation B was written. Code of Federal Regulations, Title 42, Section §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. California 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 24 hours (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 2/20/24 at 8 a.m., an unannounced visit was conducted at the facility for a Re-certification survey where facility reported incident #CA00886144 was investigated. The Department determined the facility failed to report an allegation of verbal abuse when licensed nurse (LN) 1 did not report to facility administration about Patient 1's allegation of verbal abuse. This failure resulted in a delay of an investigation of the alleged abuse and had a potential to affect Patient 1's psychological well-being. During an interview on 2/20/24, at 11:48 a.m., with Patient 1, Patient 1 stated that Patient 2 banged on the door of his room and called him the "'N" word [a derogatory word], a few nights ago and the staff did not do anything." A review of Patient 1's record on 2/18/24, at 7 a.m., signed by LN 1 indicated, "[Patient 2] had banged on [Patient 1's] door and said FU [a derogatory word] to him." During an interview on 2/20/24, at 4 p.m., the Operations Manager stated he had not been informed of the allegation of verbal abuse of Patient 1 by Patient 2. During an interview on 2/21/24, at 11 a.m., with the Director of Nursing (DON), the DON stated the incident on 2/18/24 with Patient 1 and Patient 2 should have been reported to the Administrator (ADM) but was not. During an interview on 2/21/24, at 11:20 a.m., the Administrator stated the incident between Patient 1 and Patient 2 on 2/18/24 should have been reported to her (the ADM) but was not. During an interview on 2/22/24, at 9:20 a.m., LN 1 stated Patient 1 reported to him on 2/18/24 at 7 a.m., that Patient 2 kicked on his door and said "FU" to him. LN 1 stated "I should have reported to the ADM, [the Department], and the PD [police department] when I was told about it. I got busy and forgot to report it." A review of the facility's policy and procedure titled, "Abuse, Neglect and Exploitation," dated 2023, indicated, "...Reporting of all alleged violations to the Administrator, State agency... No later than 24 hours..." Therefore, the Department determined the facility failed to report an allegation of verbal abuse when licensed nurse (LN) 1 did not report to facility administration about Patient 1's allegation of verbal abuse. This failure resulted in a delay of an investigation of the alleged abuse and had a potential to affect Patient 1's psychological well-being. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.