Other·July 17, 2023

The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a facility reported incident CA00832559. Event ID: N9MT11 Exit date: 6/19/23 Representing the Department: 3150, 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 6/14/23 at 10:14 a.m., an unannounced standard abbreviated survey was conducted at the facility, a facility reported incident regarding Patient Abuse was investigated. The facility failed to report an allegation of abuse within 24 hours for Patient 4. This failure had the potential to delay abuse investigation and compromise Patient 4's safety. Review of Patient 4's medical record indicated he was admitted on 3/12/23 and had the diagnosis of cerebral palsy (movement disorder caused by abnormal brain development). Review of a letter from the facility to the California Department of Public Health (CDPH, state survey agency), dated 3/22/23, indicated on 3/15/23 at approximately 5:00 p.m., staff heard a family member say to Patient 4 in a stern voice, "You better get your skinny [f***ing a**] up and cooperate with the therapist." Review of the facility's "Report of Suspected Dependent Adult/Elder Abuse" form, dated 3/17/23, indicated the above incident between Patient 4 and his family member was reported to the CDPH and the Ombudsman (resident advocate) via fax on 3/17/23. During an interview with the administrator (ADM) on 6/15/23 at 10:58 a.m., she confirmed that the above incident between Patient 4 and his family member occurred on 3/15/23. The ADM also confirmed the facility reported this incident to the CDPH and the Ombudsman on 3/17/23. The ADM acknowledged the incident was reported late, as it was not reported within 24 hours. Review of the facility's "Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure," revised 8/2022, indicated the facility will report allegations of abuse to the state survey agency and the Ombudsman in no later than 24 hours if the alleged abuse did not result in serious bodily injury. The facility failed to report an allegation of abuse within 24 hours for Patient 4. This failure had the potential to delay abuse investigation and compromise Patient 4's safety. This violation had a direct or immediate relationship to health, safety, or security of the patients.