Health inspection·March 11, 2024

The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a facility reported incident CA00856267. Event ID: IW0T11 Exit date: 2/9/24 Representing the Department: 38573, Health Facilities Evaluator Nurse. State Citation B was issued. F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B)Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. On 8/16/23, an unannounced standard abbreviated survey was conducted at the facility, a facility reported incident regarding Patient Abuse was investigated. The facility failed to report a potential suspicion of crime to the California Department of Public Health (CDPH) within 24 hours for Resident 1. This failure had the potential to jeopardize the protection, health, and safety of Resident 1. Review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on 4/21/2023 and readmitted on 8/15/2023 with diagnoses that included cognitive communication deficit, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on side of the body) following non traumatic intracranial hemorrhage (bleeding inside the brain; complications could include impairment in language skills, problems with swallowing, and inability to move one part of the body) affecting right dominant side, Parkinson ' s disease (disease of the nervous system marked by tremor, muscle rigidity and slow, imprecise movement), and diffuse traumatic brain injury with loss of consciousness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 7/24/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were severely impaired. During an interview on 8/16/23 at 11:10 a.m., with the social services specialist (SSS), the SSS confirmed she called CDPH on 8/15/23 at 11 a.m. not to report, but to give a heads up about a former facility employee. During an interview with the administrator (ADM) on 8/16/23 at 11:15 a.m., he confirmed the facility did not report Resident 1's unusual occurrence or allegation to CDPH until 8/16/23. The ADM acknowledged he told the SSS to call CDPH on 8/15/23 at 11 a.m. not to report, but to give a heads up about a former facility employee. The ADM further stated the allegation should have been reported to CDPH within 24 hours. During an interview with the ADM on 8/16/23 at 11:36 a.m., he stated he received a call from Resident 1 ' s responsible party (RP, person designated to make decisions on behalf of the resident) on 8/13/23. The ADM stated the RP notified him about threatening text messages regarding the care of Resident 1. During a telephone interview with Resident 1's RP on 8/15/23 at 12:28 p.m., she stated that on 8/11/23, she received a threatening message from an unknown individual that someone who worked in the facility was trying to kill Resident 1. The RP reported this to the ADM, assistant director of nursing A (ADON A), and ADON B on 8/13/23. The RP further stated she was the one who called the police and left a message with the Ombudsman (an advocate for residents in the nursing homes) on 8/14/23. During a telephone interview with the SSS on 8/16/23 at 2:43 p.m., the SSS confirmed Resident 1 ' s RP was the one who notified the police regarding the threatening message. The SSS further stated the police case number provided to CDPH was given by Resident 1 ' s RP. On 8/17/23, the ADM called the CDPH office and stated there was no report from the facility regarding the allegation. The ADM clarified that the call made to CDPH on 8/15/23 was not to report the allegation but to "alert" CDPH about a former facility employee. During a telephone interview with the Ombudsman on 8/21/23 at 8:21 a.m., she stated that it was Resident 1' s RP who left a message to the state crisis line on 8/14/23. The Ombudsman returned the call on 8/15/23 and was told by the RP about the threatening text messages about Resident 1. The ADM, ADON A, and ADON B were notified on 8/13/23. The Ombudsman stated on 8/16/23, she met with the RP in the facility and was told by the RP that she was the one who notified the police, and she was the one who gave the badge and case number to the SSS. The Ombudsman further stated she spoke with the SSS about an incomplete SOC 341 that was faxed to the Ombudsman office on 8/16/23 and the ombudsman confirmed she did not get a call from the facility. During an interview with ADON A on 8/21/23 at 4:06 p.m., she stated she received a call from Resident 1's RP informing her about threatening text messages about Resident 1' s care in the facility on 8/13/23. ADON A told the RP she would notify the ADM. ADON A stated she told the RP that ADON B got the text message from the RP and ADON B called the ADM. ADON A further stated the ADM told her he received a call from ADON B regarding the text message from the RP on 8/13/23 and would handle the situation with the SSS by Monday, 8/14/23 or Tuesday, 8/15/23. Review of the facility's policy, revised September 2022, titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," indicated, "All reports of resident abuse, including injuries of unknown origin, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies, as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported." "If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as, within two hours of an allegation involving abuse or result in serious bodily injury; or within twenty-four hours of an allegation that does not involve abuse or result in serious bodily injury. All allegations are thoroughly investigated. The administrator, or his/her designee, provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation." The facility ' s undated policy, titled "Unusual Occurrence Reporting," indicated as required by federal or state regulations, facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of residents, employees, or visitors .... Allegations of abuse, neglect, and misappropriation of resident property; and other occurrences that interfere with facility operations and affect the welfare, safety or health of residents, employees, or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. The facility failed to report a potential suspicion of crime to the California Department of Public Health (CDPH) within 24 hours for Resident 1. This failure had the potential to jeopardize the protection, health, and safety of Resident 1. The above violations had a direct or immediate relationship to the health, safety, or security of patients.