Other·July 19, 2023

Health and Safety Code Section 1418.91(a)(b). (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 2/7/23 at 1 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of resident abuse reported by a student nurse. In addition, to investigate a Facility Reported Incident (FRI) regarding a resident fall that resulted in a rib fracture. The Department determined during the investigation, the facility failed to report an allegation of abuse to the Department after a student nurse (SN) brought it to the attention of the Administrator-in-Training (ADMT) and the Director of Nurses (DON). Record review indicated Resident 1 was a 77-year-old male with diagnoses that included, abnormal gait and mobility (abnormal walking), Alzheimer's disease (a disease of the brain that affects thinking), and history of a fall. The facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting," dated July 2017 indicated, "All reports of resident abuse, neglect...and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further abuse, neglect, exploitation, or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. All alleged violations involving abuse, neglect...or mistreatment, including injuries of an unknown source...will be reported by the facility administrator, or his/her designee, to the following persons and or agencies: the state licensing/certification agency, the local/state ombudsman, the resident's representative (sponsor) of record, adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director. An alleged violation of abuse...will be reported immediately, but not later than 2 hours if the alleged violation involves abuse." During a concurrent interview and record review on 2/6/23, at 4:50 p.m., with the SN, an "Incident Report (IR)," dated 1/30/23 regarding Resident 1 was reviewed. The IR indicated, at approximately 8 a.m., Resident 1 was observed leaving the facility. The SN followed Resident 1 and attempted to redirect the resident back to the facility. A Licensed Nurse (LN1) approached Resident 1 with anger and stated, "We are not going to deal with this shit today". The SN stated, LN1 very aggressively linked his arm under Resident 1's arm and twirled him around so quickly the resident lost his footing, fell to the ground hard, hitting the left side of his cheek first, and then LN1 fell on top of Resident 1. LN1 did not assess if Resident had injuries. LN1 then scooped Resident 1 up off the ground, dragging him back to the facility and plopped hm on the couch. Resident 1 complained he couldn't breathe. The SN stated, the ADMT called her into his office, and she told him everything that happened, and the SN stated, "I am so shaken up about the situation, it's really abusive." The SN told the DON that morning also. The SN asked the DON, "Why are we not sending (Resident 1's name) out to the hospital? He hit his head hard." The DON responded to the SN, Resident 1's vital signs were fine, so the resident doesn't need to be sent out. The SN indicated an x-ray confirmed Resident 1 had a fractured rib. During a review of the "Central Coast Portable Imaging Radiology Interpretation (CCPI), "dated 1/27/23, for Resident 1, the CCPI indicated x-rays completed for left shoulder, left hand, right hand, and chest. The CCPI indicated, fracture of left seventh rib (broken rib). During an observation and concurrent interview on 2/7/23, at 1:27 p.m., Resident 1 was observed standing in the doorway of room. Resident 1 was alert to name and able to answer simple questions. Resident 1 looked at surveyor badge and stated, "Another girl had one of these. This guy pushed me on the ground and fell on top of me. He thought he was being cute. I said you're a tough guy huh. Made me really angry, thought he was being cute." When asked if resident had any injuries, Resident 1 demonstrated hard to breath with fast and shallow inspirations and showed both hands that have reddish, purplish, brown discoloration on fingers and anterior of both hands. Resident 1 then looked down the hallway and saw LN1 and stated, "That's the guy". Resident 1 motioned towards LN1, pointing with finger, "The one that thought he was being cute". Resident 1 appeared fearful and concerned and watched LN1 who was about 20 feet away until LN1 was no longer there. Resident 1 stated," Being pushed down made me feel horrible, that guy thought he was being cute." During a review of LN1's "Time Sheet (TS)," dated 2/7/23, the TS indicated, LN1 continued to work until 6:27 p.m. on 1/27/23 despite the DON and ADMT being informed of the alleged abuse that morning by the SN. During a concurrent interview and record review on 2/7/23, at 1:50 p.m., with the DON, ADMT, and the SN, the facility P&P, "Abuse Investigation and Reporting," was reviewed. The ADMT and the DON confirmed the facility did not follow the policy when a SN reported suspected abuse and should have. This facility failure is a violation of the Health and Safety Code (H&SC) 1418.91 (a)(b) which mandates facilities to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.