Other·August 29, 2022

The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for FACILITY REPORTED INCIDENT CA00786974 which resulted in Dual Enforcement, a Class B Citation (Event ID 2P9011). Representing the California Department of Public Health: Surveyor 40797, HFEN. §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure one sampled resident (Resident 1) was free from physical abuse. * A facility staff (CNA 2) was witnessed by another facility staff poking Resident 1 on the side of his ribs, pulling him down by his shirt, forcing him to sit down, and pinching Resident 1 on the side of his body. This failure had the potential to cause physical and psychosocial harm to Resident 1. Findings: Review of the facility's P&P titled Policy of Abuse Reporting and Prevention revised February 2022 showed under the sections for V-Investigation and VI-Protection, when the incidents involving the health, welfare, or safety of residents, including suspected abuse are reported, the Administrator shall provide a safe environment for the residents and suspend the employees during the investigation in accordance with personnel policies and state law. Medical record review for Resident 1 was initiated on 6/8/22. Resident 1 was admitted to the facility on 2/18/22 and readmitted on 3/23/22. Review of Resident 1's MDS dated 3/21/2022, showed Resident 1 was severely cognitively impaired. Review of the facility's Incident Report dated 5/23/22, showed between 0700 and 1500 hours on 5/23/22, the Activities Assistant observed Resident 1 verbalizing that he wanted to go home and was standing up off his wheelchair. CNA 2 asked Resident 1 to sit down; however, Resident 1 was not cooperative. CNA 2 was then pinching Resident 1's side of body and shoving her finger on one of Resident 1' side. Review of the facility ' s investigation summary report dated 5/28/22, showed the allegation of physical abuse wherein CNA 2 pinched Resident 1 was substantiated by the facility. On 6/29/22 at 1359 hours, a telephone interview was conducted with the Activities Assistant. When asked if there was an incident occurred between Resident 1 and a staff member, the Activities Assistant stated yes, Resident 1 was abused. The Activities Assistant further stated she was in the dining room when she witnessed CNA 2 poking Resident 1 on the side of his ribs, pulling him down by his shirt, forcing him to sit down, and pinching Resident 1. The Activities Assistant further stated she could see CNA 2 was trying to stop Resident 1 from getting out of his wheelchair; however, the way CNA 2 did, it was not right. When asked how Resident 1 responded, the Activities Assistant stated Resident 1 was yelling that he wanted to go home and was overheard saying "ouch" and responding like someone would respond if they were having pain. The Activities Assistant further stated she reported the incident immediately to LVN 1 who reported it to the Administrator. On 6/8/22 at 0846 hours, an interview was conducted with the Administrator. The Administrator stated CNA 2 had no longer worked at the facility, and the facility had substantiated the allegation of abuse. On 6/30/22 at 0851 hours, a telephone interview was conducted with the DON. The DON verified the above findings and stated the facility had substantiated the physical abuse towards Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of the client. §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, The facility failed to ensure the resident was protected from a continued risk of abuse from the alleged staff and the allegation of a staff-to-resident abuse was reported timely as per the facility ' s P&P for one of two sampled (Resident 1). This failure had the potential to result in physical abuse going uninvestigated by the proper authorities and further abuse of other residents within the facility. Findings: Review of the facility's P&P titled Policy of Abuse Reporting and Prevention revised February 2022 showed the following: - under the section titled Reporting Procedure: If the charge nurse is notified, the charge nurse will immediately notify the Administrator, Abuse Coordinator, and Director of Nursing. - The Administrator or his/her designee will report each alleged abuse to the Ombudsman's office and CDPH immediately or within two hours. - If the suspected abuser is an employee, remove the employee immediately from the care of all residents. Review of the facility's Incident Report dated 5/23/22, showed between 0700 and 1500 hours on 5/23/22, the Activities Assistant observed Resident 1 verbalizing that he wanted to go home and was standing up off his wheelchair. CNA 2 asked Resident 1 to sit down; however, Resident 1 was not cooperative. CNA 2 was then pinching Resident 1's side and shoving her finger on one of Resident 1'side. Review of the facility's investigation summary report dated 5/28/22, showed the allegation of physical abuse wherein CNA 2 pinched Resident 1 was substantiated by the facility. a. On 5/24/22, the CDPH, L&C Program received a report from the facility that a facility staff (CNA 2) pinched the side of Resident 1's body while he was in the dining room on 5/23/22. On 6/29/22 at 1359 hours, a telephone interview was conducted with the Activities Assistant. The Activities Assistant stated she witnessed CNA 2 poking Resident 1 on the side of his ribs, pulling him down by his shirt, forcing him to sit down, and pinching Resident 1. The Activities Assistant stated she reported the incident immediately to LVN 1. On 6/29/22 at 1429 hours, a telephone interview was conducted with LVN 2. LVN 2 stated the Activities Assistant reported to her that she saw CNA 2 being rough with Resident 1, pushing him down and pinching Resident 1's side. LVN 1 stated she reported the incident to the DSD. Further review of the facility's Investigation of Incident/Accident/Injury of Unknown Origin showed the date of the incident was 5/23/22; however, the Administrator was notified on 5/24/22. On 6/30/22 at 0851 hours, a telephone interview was conducted with the DON. The DON verified the incident took place on 5/23/22 and was witnessed by the facility staff. The DON verified the incident was not reported in a timely manner as per the facility's P&P. b. Review of the facility's Daily Sign in Sheets dated 5/23 and 5/24/22, showed CNA 2 had signed the attendance log and reported for work. Review of the CNA 2's timecards showed on 5/23/22, CNA 2 clocked in to work at 0627 hours and clocked out of work at 1504 hours, and on 5/24/22, CNA 2 clocked in to work at 0630 hours; however, there was no clock-out time documented for CNA 2 on 5/24/22. On 6/30/22 at 0851 hours, a telephone interview was conducted with the DON. The DON verified CNA 2 was allowed to complete the shift on 5/23/22, after the abuse had been witnessed and reported to the facility staff. In addition, CNA 2 was allowed to return to work on 5/24/22, and had access to all residents in the facility and should not have been as per the facility's P&P. This violation had a direct or immediate relationship to the health, safety, or security of the client.