Other·June 5, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident CA00896615. Event ID: T53D11 Representing the Department, HFEN #2934 State Citation B was written. F600 §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. On 5/14/24, an unannounced visit was conducted at the facility to investigate Facility Reported Incident regarding Resident Abuse. The facility failed to ensure Resident 1 was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1. Review of Resident 1's admission record indicated she was admitted to the facility on 7/7/20 with diagnoses including vascular dementia (brain damage caused by multiple strokes [occurs when blood supply going to the brain is blocked or reduced] and cognitive communication deficit (trouble participating in conversations). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/21/24 indicated her Brief Interview for Mental Status (BIMS, a tool used to have a snapshot of a resident cognitive function) was "00" (score of 0 to 7 indicates severe cognitive impairment). Review of Resident 2's admission record indicated he was admitted to the facility on 3/23/18 with diagnoses including Alzheimer's disease (a progressive disease that affects memory and other mental functions) and dementia (loss of cognitive function like thinking, remembering, and reasoning). Review of Resident 2's MDS dated 2/22/24 indicated his BIMS score was 5. Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a verbal or written communication tool used by healthcare professional) date 4/19/24, indicated at approximately 7:14 p.m., Resident 3 went to the activity room and witnessed Resident 2 putting his hands inside Resident 1's pants. Resident 3 called Registered Nurse A (RN A) and RN A went to the activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh. During an interview with RN A on 4/25/24 at 2:30 p.m., RN A stated when Resident 3 called her attention she immediately went to activity room and saw Resident 2's hands inside Resident 1's pants touching her inner thigh. RN A further stated Resident 1 was wearing above knee-length loose pants at that time. During an interview with Licensed Vocational Nurse B (LVN B) on 4/29/24 at 1 p.m., she stated the activity room had supervision during daytime and after 6 p.m., there will be no staff supervising the activity room. During an interview with Resident 3 on 4/29/24 at 1:40 p.m., she stated she was the first person who witnessed Resident 2 touched Resident 1's "private part" because there was no staff around. Resident 3 further stated Resident 2 knew what he was doing because when he saw her, he immediately stopped. Review of Resident 3's MDS dated 2/26/24 indicated her BIMS score was 13 (score of 13-15 indicates cognition [process of acquiring knowledge and understanding] is intact). During an interview with Certified Nursing Assistant C (CNA C) on 4/29/24 at 3:45 p.m., CNA C stated she worked on 4/19/24 evening shift and Resident 1 was under her care. CNA C stated at 7:14 p.m., she was taking her break and asked other CNAs to watch out the residents assigned to her. CNA C further explained that she was supposed to take her break from 6 p.m., to 6:30 p.m. but was delayed on that day and was not able to watch Resident 1. Review of the facility's policy and procedure titled, "Abuse Policy," dated 7/2015 indicated "The facility will prohibit abuse including sexual abuse. To ensure that the facility staff are doing all that is within their control to prevent occurrence of abuse including neglect ...for all patients." The facility failed to ensure Resident 1 was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room and Resident 2 touched Resident 1's inner thigh. This failure had the potential to endure emotional and psychological harm for Resident 1. This failure had direct relationship or immediate relationship to the health, safety, and security of the resident.