Health inspection·March 6, 2023

Class B Citation - Patient Care Citation F607 §483.12(b) The facility must develop and implement written policies and procedures. The facility failed to implement facility's written abuse policy and procedure (P&P) for one out of four sampled resident (Resident 1) when: 1. Facility failed to notify Resident 1's verbal abuse allegation to the California Department of Public Health (CDPH), Ombudsman, and Local Law Enforcement within 2 hours after facility aware of the abuse allegation; 2. Alleged suspected certified nursing assistance A (CNA A) was not suspended immediately and CNA A was assigned on next shift on the same day to provide care for Resident 1. These failures had the potential to affect the resident's psychosocial well-being, further abuse, and delayed abuse allegation investigation. Review of Resident 1's clinical record indicated he was admitted to the facility on 1/6/2023, with diagnoses including diabetes mellitus (increased blood sugar), hypertension (increase in blood pressure), benign prostatic hyperplasia (enlarged prostate gland), and muscle weakness (reduced strength in one or more muscles). Resident 1's minimum data set (MDS, an assessment tool) dated 1/22/23, indicated he was cognitively intact (no memory problem). Further review of Resident 1's clinical record indicated Resident 1's daughter reported CNA A told Resident 1 to shut up during his care in the morning on 1/21/23. Resident 1's daughter reported the allegation to LVN B on 1/21/23 at around 10 a.m. During an interview with Resident 1 on 1/30/23, at 11:00 a.m., Resident 1 stated CNA A told him to shut up when he asked her to slow down during his care on 1/21/23 in the morning. He also stated he reported to his daughter same day. Resident 1 further stated CNA A continued to take care of him until 11 p.m., on 1/21/23. During an interview with director of nursing (DON) on 1/30/23 at 12:45 a.m., the DON stated LVN B did not report the allegation of abuse to the California Department of Public Health (CDPH), Ombudsman, and Local Law Enforcement within 2 hours, and did not separate CNA A from Resident 1 after the incident of abuse. She also stated any facility staff who received allegation of abuse should report to the abuse coordinator and should have suspended CNA A immediately. During an interview with facility's administrator (ADMN) on 1/30/23 at 1:00 p.m., the ADM acknowledged LVN B did not report abuse allegation on 1/21/23, and did not separate CNA A from Resident 1. ADM further stated LVN B should have reported the incident to the California Department of Public Health (CDPH), Ombudsman, and Local Law Enforcement within 2 hours and suspended CNA A immediately. During phone interview with LVN B on 2/2/23 at 3:10 p.m., the LVN B stated Resident 1 's daughter reported CNA A stated "shut up" to Resident 1 on 1/21/23 at around 10:00 a.m. She acknowledged she did not report to abuse coordinator and other necessary entities on 1/21/23. She also stated accused CNA A was not removed from Resident 1. She further stated she should have reported to the abuse coordinator and removed accused CNA immediately from Resident 1. Review of facility's daily staffing sheet record indicated CNA A was assigned to Resident 1 from 7 a.m. up to 3 p.m., (morning shift) and 3 p.m., to 11 p.m., (evening shift) on 1/21/23. Review of the facility's policy and procedure (P&P) titled, "Abuse-Reporting & Investigations", revised July 2018, the P&P indicated, "If the suspected perpetrator was an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities policies". "Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury"- A. The Administrator or designated representative will notify within two (2) hours notify by telephone, CDPH, the Ombudsman, and Law Enforcement". B. The administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours". In violation of the above cited standards, the facility failed to implement facility's written abuse policy and procedure (P&P) for one out of four sampled resident (Resident 1). This violation had a direct or immediate relationship to the health, safety, or security of the patients.