Other·June 13, 2024

The following reflects the findings of the California Department of Public Health during the reinvestigation of Complaint CA00851514. Event ID: 3WYB11 Representing the Department: 44583, Health Facilities Evaluator Nurse A Class "B" Citation was written for the following violation: WIC 15630 (b)(1)(A)(i)(ii) W & I 15630-15630. (a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days: (A) If the suspected or alleged abuse is physic (B) Notwithstanding the rulemaking provisions o (C) If the suspected or alleged abuse is abuse (D) With regard to abuse reported pursuant to s (E) If the suspected or alleged abuse occurred (F) If the abuse has occurred any place other (2) (A) A mandated reporter who is a clergy member who acquires knowledge or reasonable suspicion of elder or dependent adult abuse during a penitential communication is not subject to paragraph (1). For purposes of this subdivision, " penitential communication " means a communication that is intended to be in confidence, including, but not limited to, a sacramental confession made to a clergy member who, in the course of the discipline or practice of his or her church, denomination, or organization is authorized or accustomed to hear those communications and under the discipline tenets, customs, or practices of his or her church, denomination, or organization, has a duty to keep those communications secret. (2)(B) This subdivision shall not be construed to modify or limit a clergy member ' s duty to report known or suspected elder and dependent adult abuse if he or she is acting in the capacity of a care custodian, health practitioner, or employee of an adult protective services agency. (2)(C) Notwithstanding any other provision in this section, a clergy member who is not regularly employed on either a full-time or part-time basis in a long-term care facility or does not have care or custody of an elder or dependent adult shall not be responsible for reporting abuse or neglect that is not reasonably observable or discernible to a reasonably prudent person having no specialized training or experience in elder or dependent care. (3)(A) A mandated reporter who is a physician and surgeon, a registered nurse, or a psychotherapist, as defined in Section 1010 of the Evidence Code, shall not be required to report, pursuant to paragraph (1), an incident if all of the following conditions exist: (i) The mandated reporter has been told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect. (ii) The mandated reporter is not aware of any independent evidence that corroborates the statement that the abuse has occurred. (iii) The elder or dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservatorship because of a mental illness or dementia. (iv) In the exercise of clinical judgment, the physician and surgeon, the registered nurse, or the psychotherapist, as defined in Section 1010 of the Evidence Code, reasonably believes that the abuse did not occur. (b)(3)(b) This paragraph shall not be construed to impose upon mandated reporters a duty to investigate a known or suspected incident of abuse and shall not be construed to lessen or restrict any existing duty of mandated reporters. (4)(A) In a long-term care facility, a mandated reporter shall not be required to report as a suspected incident of abuse, as defined in Section 15610.07, an incident if all of the following conditions exist: (i) The mandated reporter is aware that there is a proper plan of care. (ii) The mandated reporter is aware that the plan of care was properly provided or executed. (iii) A physical, mental, or medical injury occurred as a result of care provided pursuant to clause (i) or (ii). (iv) The mandated reporter reasonably believes that the injury was not the result of abuse. (4)(B) This paragraph shall not be construed to require a mandated reporter to seek, nor to preclude a mandated reporter from seeking, information regarding a known or suspected incident of abuse prior to reporting. This paragraph shall apply only to those categories of mandated reporters that the State Department of Public Health determines, upon approval by the Bureau of Medi-Cal Fraud and Elder Abuse and the state long-term care ombudsman, have access to plans of care and have the training and experience necessary to determine whether the conditions specified in this section have been met. (4)(c)(1)Any mandated reporter who has knowledge, or reasonably suspects, that types of elder or dependent adult abuse for which reports are not mandated have been inflicted upon an elder or dependent adult, or that his or her emotional well-being is endangered in any other way, may report the known or suspected instance of abuse. (4)(c)(2) If the suspected or alleged abuse occurred in a long-term care facility other than a state mental health hospital or a state developmental center, the report may be made to the long-term care ombudsman program. Except in an emergency, the local ombudsman shall report any case of known or suspected abuse to the State Department of Public Health and any case of known or suspected criminal activity to the Bureau of Medi-Cal Fraud and Elder Abuse, as soon as is practicable. (4)(c)(3) If the suspected or alleged abuse occurred in a state mental health hospital or a state developmental center, the report may be made to the designated investigator of the State Department of State Hospitals or the State Department of Developmental Services or to a local law enforcement agency. Except in an emergency, the local law enforcement agency shall report any case of known or suspected criminal activity to the Bureau of Medi-Cal Fraud and Elder Abuse, as soon as is practicable. (4)(c)(4) If the suspected or alleged abuse occurred in a place other than a place described in paragraph (2) or (3), the report may be made to the county adult protective services agency. (4)(c)(5) If the conduct involves criminal activity not covered in subdivision (b), it may be immediately reported to the appropriate law enforcement agency. (4)(d) If two or more mandated reporters are present and jointly have knowledge or reasonably suspect that types of abuse of an elder or a dependent adult for which a report is or is not mandated have occurred, and there is agreement among them, the telephone report or Internet report, as authorized by Section 15658, may be made by a member of the team selected by mutual agreement, and a single report may be made and signed by the selected member of the reporting team. Any member who has knowledge that the member designated to report has failed to do so shall thereafter make the report. (4)(e) A telephone report or Internet report, as authorized by Section 15658, of a known or suspected instance of elder or dependent adult abuse shall include, if known, the name of the person making the report, the name and age of the elder or dependent adult, the present location of the elder or dependent adult, the names and addresses of family members or any other adult responsible for the elder ' s or dependent adult ' s care, the nature and extent of the elder ' s or dependent adult ' s condition, the date of the incident, and any other information, including information that led that person to suspect elder or dependent adult abuse, as requested by the agency receiving the report. (4)(f) The reporting duties under this section are individual, and no supervisor or administrator shall impede or inhibit the reporting duties, and no person making the report shall be subject to any sanction for making the report. However, internal procedures to facilitate reporting, ensure confidentiality, and apprise supervisors and administrators of reports may be established, provided they are not inconsistent with this chapter. (g)(1) Whenever this section requires a county adult protective services agency to report to a law enforcement agency, the law enforcement agency shall, immediately upon request, provide a copy of its investigative report concerning the reported matter to that county adult protective services agency. (g)(2) Whenever this section requires a law enforcement agency to report to a county adult protective services agency, the county adult protective services agency shall, immediately upon request, provide to that law enforcement agency a copy of its investigative report concerning the reported matter. (g)(3) The requirement to disclose investigative reports pursuant to this subdivision shall not include the disclosure of social services records or case files that are confidential, nor shall this subdivision be construed to allow disclosure of any reports or records if the disclosure would be prohibited by any other provision of state or federal law. (h) Failure to report, or impeding or inhibiting a report of, physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult, in violation of this section, is a misdemeanor, punishable by not more than six months in the county jail, by a fine of not more than one thousand dollars ($1,000), or by both that fine and imprisonment. Any mandated reporter who willfully fails to report, or impedes or inhibits a report of, physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult, in violation of this section, if that abuse results in death or great bodily injury, shall be punished by not more than one year in a county jail, by a fine of not more than five thousand dollars ($5,000), or by both that fine and imprisonment. If a mandated reporter intentionally conceals his or her failure to report an incident known by the mandated reporter to be abuse or sever (i) For purposes of this section, " dependent adult " shall have the same meaning as in Section 15610.23. On 3/6/2024, an unannounced visit was conducted at the facility to reinvestigate a complaint regarding Resident/Patient/Client Abuse. The facility failed to report and investigate an abuse allegation for Resident 1 and Resident 2. This failure resulted in an alleged abuse incident not reported to required agencies (CDPH, law enforcement agency and LTC ombudsman) and the facility did not investigate this alleged abuse incident. This failure had the potential to compromise the safety of the residents in the facility. Review of Resident 1's Admission Record dated 3/6/2024, indicated Resident 1 was admitted to the facility on 6/14/2023 with diagnoses including displaced fracture (the trauma moves the bone fragments out of alignment) of base of neck of left femur (hip bone), presence of left artificial hip joint, displaced fracture of left radial styloid process (a bone found in the wrist area), displaced fracture of left ulna styloid process (another bone found in the wrist area) and history of falling. Review of Resident 1's admission minimum data set (MDS, an assessment tool) assessment dated 6/16/2023, indicated Resident 1's brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 13 [score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. Review of Resident 1's nurse's notes dated 6/15/2023, indicated, "Around 9:30 p.m. as CNAs (certified nursing assistants) were making rounds to check on their groups, a resident was noted calling out for help...2 CNAs rushed to the room and noted Resident (#2) was sitting at the foot of the bed (on Resident 1)...This LN (licensed nurse) went to check on 'Resident 1' and asked what happened to which 'Resident 1' replied that there was a patient who came over and sat down at the foot of the bed...Resident (#1) was anxious for the time being about the Resident (#2)..." Review of Resident 1's nurse's notes dated 6/16/2023, indicated, Resident 1 was discharged home against medical advice (AMA) on 6/16/2023. The daughter signed the AMA papers. During an interview with certified nursing assistant A (CNA A) on 3/6/2024 at 2:30 p.m., CNA A confirmed she was assigned to Resident 1 on 6/15/2023. CNA A stated, she was doing her rounds on 6/15/2023 at around 9:30 p.m. with another CNA. CNA A further stated, she was in Room AA when she heard the call light and there was somebody yelling for help. CNA A stated, she ran to check who was yelling and found out it was Resident 1 yelling while she was lying on her bed. CNA A confirmed she found Resident 2 seated at the left side of the foot of the bed. CNA A stated, Resident 1 did not know Resident 2. CNA A stated, she took Resident 2 out of the room because Resident 1 was yelling and then she reported to the nurse. CNA A further stated, the nurse talked to Resident 1 because she was so scared of Resident 2. During an interview with director of nursing (DON) on 3/8/2024 at 10:39 a.m., DON stated, she got a report from the CNA and nurses about the incident on 6/15/2023 with Resident 1 and 2. DON confirmed Resident 1 informed her that Resident 2 sat at the foot of her bed and requested to transfer out of the facility. DON stated, they tried to transfer Resident 1 to another facility but since it was a weekend, they were not able to do so. DON further stated, Resident 1 and her daughter decided to just take her home and went AMA. DON stated she did not suspect the incident as an alleged abuse because she thought Resident 1 just wanted to go home. During an interview with administrator in training (AIT) on 3/8/2024 at 11:04 a.m., AIT stated she got a call on the night of 6/15/2023 about the incident. AIT stated Resident 1's family member A (FM A) came to visit on 6/16/2023 and the daughter told AIT, "Mom is not safe due to residents are demented." AIT stated they did not report the incident because they never thought it was a possible alleged abuse and she confirmed there was no investigative report completed regarding the incident. During a phone interview with Resident 1's family member B (FM B) on 3/8/2024 at 1:17 p.m., Resident 1's FM B confirmed Resident 1 told him Resident 2 went to her room. Resident 1's FM B stated, "mom was afraid. She was scared for her life. She could have been killed that night." Resident 1's FM B further stated, "we took her home because she was scared for her life." During a concurrent phone interview with Resident 1 and her family member C (FM C) on 3/13/2024 at 9:46 a.m., Resident 1 stated, "on Thursday night, I was lying in bed watching TV, there was this guy who entered my room, and sat down on my bed. I rang the bell, but nobody came. The guy laid down on my broken leg and arm, and I started screaming." Resident 1 confirmed she started to see a therapist a