Other·May 6, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident CA00838453. Event ID: YEW511 Representing the Department, HFEN # 3150 State Citation B was written. 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. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (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. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 4/9/24, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Quality of Care/Treatment. The facility failed to follow its abuse reporting policy for Resident 1. This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility. Review of Resident 1's medical record indicated Resident 1 was admitted on 2/17/22 and had diagnoses including major depressive disorder (a mental condition characterized by long-term loss of interest or pleasure in life) and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 1's Progress Notes, dated 4/29/23, indicated licensed nurse A (LN A) witnessed Resident 1 yelling and cursing at another resident. The Progress Notes indicated Resident 1 then pushed the other resident's wheelchair with such force that the wheelchair rolled approximately 20 feet before coming to rest. Resident 1 then yelled, "And don't come back!" There was no documentation that indicated LN A reported this incident to anyone. During an interview and concurrent record review with LN B on 4/9/24 at 10:50 a.m., LN B reviewed Resident 1's 4/29/23 Progress Notes. LN B confirmed Resident 1's documented actions were considered abuse and should have been reported. LN B explained incidents of abuse should be reported to the facility's abuse coordinator. LN B stated the abuse coordinator would then report the incident to the Ombudsman (resident advocate), the California Department of Public Health (CDPH, State licensing and certification agency), and if necessary, the police. During a follow-up interview with LN B on 4/9/24 at 1:58 p.m., in the presence of administrative staff C (AS C), LN B confirmed there was no documentation that the incident involving Resident 1 on 4/29/23 was reported to the facility's abuse coordinator, the Ombudsman, CDPH, or the police. During a telephone interview with LN A on 4/9/24 at 2:11 p.m., LN A indicated she vaguely remembered the incident involving Resident 1 on 4/29/23. LN A stated she did not remember if she reported the incident. The facility's policy titled "Abuse Investigation and Reporting," revised 7/2017 indicated, "All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director." The facility failed to follow its abuse reporting policy for Resident 1. This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.