Other·June 26, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00893301 Facility Reported Incident # CA00893751 and CA00895005 Event ID: JEB511 Representing the Department, HFEN # 44733 State Citation B was written. §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §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. On 4/08/24 at 9:20 a.m., an unannounced visit was conducted at the facility for an abbreviated survey. The facility failed to implement their abuse policy and procedure (P&P) when: 1. For Resident 1, staff did not report an incident of potential abuse to the state agency and other required agencies; and 2. The facility did not provide abuse training to all staff at least quarterly. These failures had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse. 1. Review of Resident 1's clinical record indicated he was admitted on 7/26/23 and had the diagnoses including cerebral infarction (known as a stroke, a damage to tissues in the brain due to a loss of oxygen), difficulty in walking, muscle weakness, aphasia, type 2 diabetes (high blood sugar), hypertension (high blood pressure), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/22/24, indicated he had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 9 (moderate cognitive impairment). During an interview on 4/8/24 at 11:30 a.m. with Resident 1, he stated that physical therapist A (PT A) came to his room on 4/3/24 at 7 a.m. The visit was not announced and was too early. Resident 1 did not like PT A's approach and asked him to leave the room. PT A did not leave the room and yelled at Resident 1, "You got a problem." Staff came into Resident 1's room, and PT A left the room after the staff asked him to leave multiple times. During an interview on 4/8/24 at 11:45 a.m. with Resident 2, who shared the room with Resident 1, he stated that PT A came to his room on 4/3/24 around 7:15 a.m. Resident 1 and PT A started to argue and yell at each other. Resident 1 asked PT A to leave the room, but PT A kept yelling at Resident 1. The director of staff development (DSD) came into the room, and PT A left the room after the DSD asked him to leave multiple times. Review of Resident 1's clinical record indicated there was no documentation of the incident involving Resident 1 on 4/3/24. Review of the SOC 341 (a document used to report elderly abuse) filed by the facility dated 4/15/24 indicated Resident 1's family member alleged the resident was verbally and emotionally abused by a physical therapist on 4/3/24. During an interview on 4/8/24 at 11:55 a.m. with licensed vocational nurse B (LVN B), he stated that he heard yelling at the nurse station on 4/3/24 around 7 a.m. Resident 1 and PT A were yelling at each other. Resident 1 was kept yelling at PT A to leave the room. LVN B stated he reported it to the DSD. The DSD came into the room and asked PT A to leave the room, but PT A kept yelling at Resident 1. PT A left the room after the DSD asked him to leave a couple of times. LVN B stated Resident 1 looked very upset, and PT A's approach was not acceptable. LVN B further stated it was a reportable incident, but he did not report or document because the DSD said she would report and document. During an interview on 4/8/24 at 12:53 p.m. with the DSD, she stated that she was called by LVN B on 4/3/24 around 7:15 a.m. Resident 1 was still in bed and upset. Resident 1 and PT A were yelling at each other. Resident 1 yelled at PT A to get out of his room, and PT A did not leave the room. The DSD asked PT A to leave the room because Resident 1 was upset, but PT A stayed in the room. PT A left the room after the DSD asked him to leave three times. The DSD stated that she reported to the administrator (ADM) and the director of nursing (DON) because it was a reportable incident for potential verbal and/or emotional abuse. The DSD further stated that the resident had a right to refuse, PT A should have respected the resident's wish then and could revisit the resident when the resident was ready for the therapy. During an interview on 4/8/24 at 2 p.m. with the ADM, he confirmed the incident involving Resident 1 was reported to him on 4/3/24. The ADM stated that he interviewed Resident 1, and Resident 1 said he did not like PT A's approach and requested not to work with PT A. The ADM stated that he filed a grievance and removed PT A from Resident 1's therapy schedule. PT A said he was raising his voice, not yelling, to redirect Resident 1. The ADM further stated that he did not report the incident to the state agency or other agencies because Resident 1 did not mention yelling, arguing, or being abused during his interview on 4/3/24. The ADM confirmed that he did not interview staff who witnessed the incident on 4/3/24. During a telephone interview on 4/9/24 at 7:15 a.m. with certified nurse assistant C (CNA C), she stated that she heard a loud voice from the room on 4/3/24 around 7 a.m. and went into the room. Resident 1 was in bed and very upset. Resident 1 was kept screaming at PT A to get out of the room and saying that it was too early. PT A looked upset and kept saying that Resident 1 needed to get ready for exercise. PT A continued to argue with Resident 1 and left the room after the DSD asked him to leave multiple times. CNA C further stated that PT A's approach was not acceptable and should be reported. During a telephone interview on 4/9/24 at 7:39 a.m. with CNA D, he stated that he was assigned for Resident 1 and 2 on 4/3/24. Around 7 a.m., Resident 1 was agitated in bed and yelled at PT A to get out of the room. PT A looked upset and confrontational to Resident 1. CNA D stated he reported it to LVN B because PT A's confrontational approach was inappropriate, and he considered it a reportable incident for possible abuse. PT A continued to argue with Resident 1 and left the room after the DSD asked him to leave the room multiple times. During a follow-up interview on 6/3/24 at 1:15 p.m. with the DSD, she stated that she reported the incident involving Resident 1 to the DON and the ADM but did not document or file SOC 341. The DSD acknowledged that she was a mandated reporter, and all alleged violations should be reported to the ADM and all required agencies. During an interview on 6/03/24 at 1:55 p.m. with the ADM, he stated Resident 1's family member filed a grievance about PT A's approach toward Resident 1 on 4/11/24, which he reviewed on 4/15/24. The family member said Resident 1 was verbally and emotionally abused by PT A. The ADM stated the facility filed SOC 341 on 4/15/24. During a review of the facility's undated "Policy and Procedure (P&P) on Patient Abuse and Prevention," the P&P indicated, "Reporting: Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation." 2. During a record review and concurrent interview on 6/3/24 at 1:04 p.m. with the DSD, she confirmed that in-service (training) sheets indicated training for abuse conducted in January 2024 (on 1/9/24, 1/15/24, 1/17/24, and 1/19/24) did not include the administrator. During a record review and concurrent interview on 6/3/24 at 2:40 p.m., she confirmed that in-service sheets indicated training for abuse conducted in January 2023 (on 1/10/23, 1/12/23, 1/13/23, and 2/07/23) and July 2023 (on 7/05/23, 7/06/23, 8/22/23) did not include the DON. The DSD acknowledged that abuse training must be provided to all employees. During a record review and concurrent interview on 6/3/24 at 2:50 p.m., in-service sheets indicated training for abuse conducted in January 2023, July 2023, and January 2024. The DSD stated that the facility provides training for abuse to all employees upon hire and twice a year. The DSD reviewed the facility's policy on abuse training and acknowledged that the facility should provide training for abuse at least quarterly. The DSD further stated she was not aware of the training frequency. During an interview on 6/3/24 at 3:30 p.m. with the ADM, he acknowledged that the facility did not implement their policy of abuse training. During a review of the facility's undated "Policy and Procedure (P&P) on Patient Abuse and Prevention," the P&P indicated, "Training: Facility staff and employees shall receive, through orientation and continuing education sessions, training on issues related to abuse prohibition practice ... Continuing education sessions on Abuse Prevention, Monitoring, Reporting, etc. shall be conducted at least once in every quarter." The facility failed to implement their abuse policy and procedure (P&P) when: 1. For Resident 1, staff did not report an incident of potential abuse to the state agency and other required agencies; and 2. The facility did not provide abuse training to all staff at least quarterly. These failures had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.